Tag: biopsychosocial model

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


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. 


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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Conservative governments are bad for your health

proper Blond 

Context: the politics of blame

Increasing employment and pushing ill and disabled people into work are key elements of the UK Government’s public health and welfare “reform” agendas. The arguments presented for this approach are primarily economic and particularly, moralistic. The reasoning presented is not founded on biological, psychological or sociological evidence. The government maintains that work is the most effective way to improve the wellbeing of individuals, their families and their communities. There is a perception that unemployment is harmful to physical and mental health, so the corollary has been assumed – that work is beneficial for health. 

However, that does not necessarily follow, and to claim that it does is distinctly unscientific and irrational. As the Conservatives themselves have often pointed out in less appropriate circumstances in order to avoid democratic accountability and responsibility, there is a difference between an association and a causal relationship.

There is a clear ideological context from which the welfare “reforms” proceeded, and the politically-directed media campaigns that have purposefully stigmatised and outgrouped unemployed people demonstrates quite clearly that reducing welfare support is not about a politically calculated extension of social inclusion and social justice policies, Conservative bonhomie, or overall concern for the wellbeing of welfare recipients and people who are disabled.

The government are attempting to entrench neoliberal ideology in our culture by co opting GPs, social workers and other professionals as agents of the state. The idea that “work is a health outcome” has been embedded in policies such as the Orwellian renaming of sick notes (now “fit notes”), which are designed to explore what work a person who is absent from work because of illness may undertake.  However, the government intend a much more far-reaching outcome than simply attempting to reduce the sick “role” and recovery time. The government’s “behavioural change” agenda has become a centrally-orchestrated programme for governance. The provision of public goods and crucial support, from housing and discretionary housing payments to employment benefits and disability support is becoming increasingly conditional. 

Political rhetoric, aimed at perpetuating an extremely divisive and intentionally misleading “strivers and skivers” dichotomy is designed to undermine public support for the welfare state and the other gains of our post-war settlement – the NHS, legal aid and social housing for example – also betrays the lack of coherence, rationality and empirical support for the Conservative’s “reforms.” Furthermore, the extremely targeted, class-contingent and punitive nature of the Conservative austerity programme indicates that the welfare “reforms” were founded on traditional Tory prejudices, rather than on any genuine causal relationship based on empirical evidence and social or economic necessity.

This explains why the government have persistently ignored the many evidence-based concerns raised by academic researchers, campaigners and opposition MPs that their austerity policies are having an extremely harmful effect, most often on our poorest and most vulnerable citizens.

The Conservatives are ideologically bound to notions of a small state, minimal levels of political responsibility and intervention, minimal levels of government spending, the heavy promotion and administration of privatisation, competition, fiscal austerity, deregulation and free trade in order to enhance the role of the private sector in the economy, all of which are the central strands of the neoliberal hegemony. Conservative ideology runs counter to any notion that all citizens must be treated fairly, which also means that they must be given equal economic opportunities and provided with a adequate minimum standard of living. Neoliberal ideology is incompatible with a human rights-based society.

Democracy exists partly to ensure that the powerful are accountable to the public, and particularly to our most vulnerable citizens. This government have blocked that crucial exchange, and show disdain for human rights, the welfare state and the NHS, all of which provides ordinary people and the most vulnerable citizens basic protection from those in power.

Conservatives despise human rights and rights-based social provision. They absurdly claim that welfare provision causes vulnerability, and a “culture of dependency,” despite the fact that there is absolutely no empirical evidence to support this view. History has consistently taught us otherwise. The Conservative’s policies are expressions of contempt for the lessons and empirical evidence from over a century of social history and administration.

Tory rhetoric is designed to have us believe there would be no poor people if the welfare state didn’t somehow “create” them. If the Conservatives must insist on peddling the myth of meritocracy, then surely they must also concede that whilst a neoliberal system has a few beneficiaries, it also creates situations of insolvency and poverty for many others. That is what a system based on competitive individualism is about: it creates a few “winners” and a lot of others lose.

Conservative cuts are based on nothing more than the ridiculous myth that poverty is somehow a lifestyle choice or a moral failing which people can be punished or starved out of. The new Tory neoliberal “paternalists” really seem to believe that if they make life for poor people insufferable, they will simply be “incentivised” to choose to be wealthier. It’s a thinly disguised revamp of the ill-conceived 1834 Poor Law deterrence principle of “less eligibility” – that was supposedly aimed at “making work pay” too. But it didn’t. It’s not possible to frighten and punish people out of poverty. Only a Conservative government would claim to be making work pay by cutting welfare down to the bare bones, rather than increasing wages. The welfare cuts have actually had the effect of driving down wages too.

Of course, by framing the issue of poverty in terms of personal responsibility and morality, the Conservatives have stifled debate and restricted public discussion in the hope that people won’t recognise the wider structural inequalities and economic failings, for which this government are solely responsible.

Debbie Abrahams said: “The Conservatives point the finger at sick and disabled people for the rise in spending. They are still shamelessly spinning their tired “shirkers” and “strivers” narrative, designed to whip up public support for cuts to the most vulnerable. But this divisive rhetoric can no longer conceal the fact their economic strategy has failed. It is the government’s failure that has led to rising social security costs. 

As we saw at the Autumn Statement (2016), borrowing is up, growth is down, deficit targets have been hopelessly missed and wages have flat-lined. At the same time, the government has refused to tackle the driving forces behind increased social security spending, from low pay to high housing costs. Instead, the government is slashing support to those who need it most, exacerbating the financial strain so many are facing this Christmas, and failing its own targets in the process.   

[…] Research by the Joseph Rowntree Foundation suggested that we need to be building 80,000 affordable homes a year to meet demand and keep the current spend on housing benefit stable. This government managed a pathetic 30,000 homes last year. It is this refusal to build enough homes that keeps the housing benefit bill growing. People are left struggling to find somewhere affordable to live, and the state is forced to subsidise the sky-high rents charged by private landlords 

We could also look at tax credits, which currently make up more than £20bn a year in the spending under the cap. Tax credits top up working people’s pay where it is insufficient. Wages today are lower than they were in 2008, and won’t even return to the levels of 2008 until 2021. A record six million workers are paid less than the living wage. This is why tax credit costs have risen – because the government has had to increase the amount spent on topping wages up. 

Labour founded the welfare state to give pensioners and disabled people dignity, to prevent homelessness, children going hungry, and to cover for periods of unemployment or ill-health. It was never designed to be spending tens of billions substituting for low-wage employers or subsidising rip-off landlords.”

Economic productivity is the new health outcome

The claim that “work is good for you” is allegedly based on “scientific evidence” that people in work tend to be healthier than those claiming unemployment and sickness benefits. However, to draw the conclusion that “employment is good for you” from the data is an example of inferring causality inappropriately, from what is only an association. Yet it is being used to prop up Conservative justifications for dismantling the welfare state.

Unemployment has been linked to increased rates of sickness, disability and mental health problems, and to decreased life expectancy. The claim has also been made that it results in an increased use of medication, medical services, and higher hospital admission rates. However, surely it makes much more sense to say that sickness, disability and mental health problems, the use of medication, medical services, and higher hospital admission rates all cause unemployment, rather than the converse. This government seem to have a major problem accepting the fact that sometimes, people really are simply too ill to work.

Most people who are too ill to work are obviously not as healthy as those who can work. That is hardly controversial. However, that doesn’t mean that work itself is good for your health, it just means those who don’t work tend to have worse health than those who do. People don’t work because they have poor health.

Linking ill health with “worklessness” is an ideological preference which ignores other variables. It is much more likely that the “reforms”, which have reduced welfare provision to inadequate levels – leaving people all too often unable to meet their basic needs – is bad for health, rather than being out of work. 

But the Conservatives have used this “evidence” of an association between poor health and unemployment to make an inference based on a “causal link” that hasn’t actually been empirically verified. Iain Duncan Smith has made the claim, for example, that “work is good for you.” He has even claimed that work can make people’s health problems “better.” But that isn’t very likely to be true. It’s akin to claiming that chatting and exercise is a cure for multiple sclerosis, lupus, blindness or cancer. Or that a work coach on prescription will cure rheumatoid arthritis, a disc prolapse or schizophrenia.

This is why I visit my doctor when I am ill, and not Iain Duncan Smith or the government.

The claim that work is good for your health is simply a part of Tory justification narratives for cutting support for sick and disabled people, and hounding people who need to claim benefits. Yet this axiom informs current UK policy towards increased benefit conditionality, harsh sanctions, compulsory work experience and the “workfare” or “work-for-benefits” thinking which the Conservatives favour. However, this is an approach that can never work, unless, of course, the aim is to completely dismantle the welfare state. Oh, hang on…

The biopsychosocial model

The biopsychosocial model (BPS) of ill health is not without controversy, although many see it as more pragmatic or humanistic than the medical model of illness, which came to be regarded as reductionist and deterministic. The biopsychosocial model is the conceptual status quo of contemporary psychiatry, and many believe that it has played an important role in combatting psychiatric dogmatism.

The biological component of the model is based on a traditional allopathic (bio-medical) approach to health. The social part of the model investigates how different social factors such as socioeconomic status, culture and poverty impact on health. The psychological component of the biopsychosocial model looks for potential psychological causes for a health problem such as lack of self-control, emotional turmoil, and negative thinking.

Of course a major criticism is that the BPS model has been used to disingenuously trivialise and euphemise serious physical illnesses, implying either a psychosomatic basis or reducing symptoms to nothing more than a presentation of malingering tactics. This ploy has been exploited by medical insurance companies (infamously by Unum Provident in the USA) and government welfare departments keen to limit or deny access to medical, social care and social security payments, and to manufacture ideologically determined outcomes that are not at all in the best interests of patients, invalidating diagnoses, people’s experience and accounts, and the existence of serious medical conditions. (See also: Getting rich on disability denial, and  A Tale of two Models by Debbie Jolly.)

Unum was involved in advising the government on making the devastating cuts to disabled people’s support in the UK’s controversial Welfare Reform Bill. (See also: The influence of the private insurance industry on the UK welfare reforms.)

This is a government that tends to emphasise citizen responsibilities over rights, moralising and psychologizing social problems, whilst quietly editing out government responsibilities and democratic obligations towards citizens.

For example, poverty, which is caused by political decisions affecting socioeconomic outcomes, is described by the Conservatives, using elaborate victim-blame narratives, and this is particularly objectionable at a time when inequality has never been greater in the UK.

Poverty may only be properly seen in a structural context, including account of the exclusion and oppression experienced by those living in poverty, the global neoliberal order, the gender order, the disability, racial, sexual and other orders which frame social life and precipitate poverty in complex and diverse ways. It’s down to policy-makers to address the structural origins of poverty, not the poor, who are currently regarded as the “collateral damage” – casualities – of politically imposed structural constraints.

Conservative governments are unhealthy

The effects of loss of income on people who can’t work because of illness is a confounding factor, too. How is it possible to isolate the devastating impacts of the Conservative “reforms” and the steady dismantling of the welfare state on unemployed people from the misleading generalisation that unemployment is bad for health? Surely if the Conservatives genuinely believed their own claims, they would be more inclined to increase rather than radically decrease provision and support for unemployed people.

Of course, not all work is beneficial. The review that led to the widespread folk tale that work is good for you is based on research involving people who had common and minor illnesses, and fulfilling, secure jobs. That doesn’t reflect the experiences of many people.

Not all jobs are rewarding and positive experiences, and some work can cause serious risks to health.

Doctor Frank Scheer, a neuroscientist at Harvard Medical School and Brigham and Women’s Hospital in Boston, says:

“There is strong evidence that shift work is related to a number of serious health conditions, like cardiovascular disease, diabetes, and obesity.

These differences we’re seeing can’t just be explained by lifestyle or socioeconomic status.”

Shift work and poor quality working environments and employment conditions are also linked to stomach problems and ulcers, hypertension, depression, musculoskeletal disorders, chronic infections, diabetes, general health complaints, all-cause mortality and an increased risk of accidents or injury. Long working hours are equally linked with a detrimental impact on health, according to medical research – see: The impact of overtime and long work hours on occupational injuries and illnesses: new evidence from the United States.

There is a growing and potentially corrosive problem of low paid, poor quality, precarious and temporary work which threatens levels of social inclusion and, ultimately, the health of the workforce.

Research shows unambiguously that the psychosocial quality of bad jobs is worse than unemployment. Peter Butterworth examined the mental health implications of those moving from unemployment into employment and found that:

“Those who moved into optimal jobs showed significant improvement in mental health compared to those who remained unemployed. Those respondents who moved into poor-quality jobs showed a significant worsening in their mental health compared to those who remained unemployed.”

Overall, unemployed respondents had poorer mental health than those who were employed. However the mental health of those who were unemployed was comparable or superior to those in jobs of the poorest psychosocial quality. (See: The psychosocial quality of work determines whether employment has benefits for mental health: results from a longitudinal national household panel survey.)

More recently, in a letter to the Guardian, the UK’s leading bodies representing psychologists, psychotherapists, psychoanalysts, and counsellors called on the Government “to immediately suspend the benefits sanctions system. It fails to get people back to work and damages their mental health.

Findings from the National Audit Office (NAO) show limited evidence that the sanctions system actually works, or is cost effective.

But, even more worrying, we see evidence from NHS Health Scotland, the Centre for Welfare Conditionality hosted by the University of York, and others, which links sanctions to destitution, disempowerment, and increased rates of mental health problems. This is also emphasised in the recent Public Accounts Committee report, which states that the unexplained variations in the use of benefits sanctions are unacceptable and must be addressed.”

The impact of poverty on health

The largest study of poverty conducted in the UK has laid out the dire extent of British material deprivation – and seriously undercut the government’s claim to be lifting people out of poverty through work.

The Poverty and Social Exclusion in the UK (PSE) project details how, over recent years, the percentage of households living below society’s minimum standard of living has increased from 14% to 33% – despite the fact that the economy has increased in size over the same period. The study found that low wages are a central cause of widespread deprivation. For many people, full-time work is not enough to lift them out of poverty; almost half of the working poor work 40 hours a week or more. And one in six adults in paid work (17%) is poor, suffering low income and unable to afford basic necessities.

Commenting on the study’s findings, Professor Jonathan Bradshaw of the University of York said they showed many parents who work full time still have to make huge sacrifices to try and protect their children from deprivation.

“We already know from DWP data that the majority of children with incomes below the the relative income poverty threshold have a working parent. The PSE survey shows that the majority of deprived children, those lacking two or more socially perceived necessities, and very deprived children (lacking five or more socially perceived necessities) have a working parent.

We found that 65% of the deprived and 58% of the very deprived children had a working parent, and 50% of the deprived and 35% of the very deprived had at least one parent working full-time. Child poverty is not being driven by skivers, but is the consequence of strivers working for low earnings while in-work benefits are being dissipated by government austerity measures.”

Responding to the findings, Clare Bambra, a professor at Durham University, said that the research was a shameful picture of “the devastating and far-reaching human costs of inequality and poverty in the UK today.”

She said:

“It’s shameful for a rich country like ours to be tolerating such levels of poverty especially amongst our children and young people. The mantra that work sets people free from poverty has been shown to be a grand old lie.

We will be living with the long term consequences of this social neglect for decades to come – there are clear links between poverty and reduced life expectancy and higher rates of ill health, especially concentrated in deprived areas and the north.

These findings show us the true cost of austerity.”

Public health experts from Durham University have denounced the impact of Margaret Thatcher’s policies on the wellbeing of the British public in a comprehensive study which examines social inequality in the 1980s.

The study, which looked at over 70 existing research papers, concludes that as a result of unnecessary unemployment, welfare cuts and damaging housing policies, the former prime minister’s legacy includes the unnecessary and unjust premature death of many British citizens, together with a substantial and continuing burden of suffering and loss of wellbeing.

The research shows that there was a massive increase in income inequality under Baroness Thatcher – the richest 0.01 per cent of society had 28 times the mean national average income in 1978 but 70 times the average in 1990, and UK poverty rates went up from 6.7 per cent in 1975 to 12 per cent in 1985.

Baroness Thatcher’s governments wilfully engineered an economic catastrophe across large parts of Britain by dismantling traditional industries such as coal and steel in order to undermine the power of working class organisations, say the researchers. They suggest this ultimately fed through into growing regional disparities in health standards and life expectancy, as well as greatly increased inequalities between the richest and poorest in society.

Professor Clare Bambra from the Wolfson Research Institute for Health and Wellbeing at Durham University, co-author of the research report, commented:

“Our paper shows the importance of politics and of the decisions of governments and politicians in driving health inequalities and population health. Advancements in public health will be limited if governments continue to pursue neoliberal economic policies – such as the current welfare state cuts being carried out under the guise of austerity.”

Thatcher’s policies  have been condemned for causing “unjust premature deaths.” Cameron’s policies are even more class-contingent and cruel.

I think there is a growing body of empirical evidence which indicates clearly that Conservative governments are much worse for public health, prosperity and wellbeing than unemployment.


Pictures courtesy of Robert Livingstone

I don’t make any money from my work. I am disabled because of illness and have a very limited income. The budget didn’t do me any favours at all.

But you can help by making a donation to help me continue to research and write informative, insightful and independent articles, and to provide support to others. The smallest amount is much appreciated – thank you.

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The new social prescribing: ask not what your government can do for you


I have a background in community work and have always seen it as a progressive mechanism for social transformation; challenging oppression; extending inclusion and democracy; offering learning and personal growth opportunities; empowerment, social justice, equity, fairness, participation, self-determination, amongst many other things. Communities potentially provide essential support for individuals, groups and organisations, and opportunities for reciprocity. Good community work promotes human development, and fosters civic responsibility through solidarity, cooperation and mutual aid.

Social prescribing is basically a community-based referral: it’s a means of enabling primary care services to refer patients with psycho-social, emotional or practical needs to a range of local, non-clinical services, often provided by the voluntary and community sector, and it’s aim is to improve people’s mental health, physical health and wellbeing, using community interventions.

In practice this means that GPs, nurses and other healthcare practitioners work with patients to identify non-medical opportunities or interventions that will help, improving support and the wider social aspects of their lives. The services that patients can choose from include everything from debt counselling, support groups, allotments and walking clubs, to community cooking classes and one-to-one coaching. Both evidence and commons sense suggests that social prescribing may be particularly appropriate and beneficial for isolated, marginalised groups. And needs-led community provision that supports and enhances psychosocial health and wellbeing is an excellent idea.

Poor mental health is often correlated with poverty, (Melzer et al. 2004) poor community integration, and competitiveness amongst social groups (Arrindell et al., 2003). Key questions arise as to the efficacy, therefore, of working with individuals, when much research suggests community work would be more effective (Orford, 2008).

So far so good.

I had the following message yesterday from friend and fellow writer, Linda:

“I have received an email from my local Tory MP letting me (and other constituents) know that he is going to be setting up a ‘Mental Health Surgery’ Hub with a ‘Mental Health Expert’ who will be handing out ‘social Prescriptions’ as he says he is aware that many mental health problems are caused by ‘Social Problems’. Im wondering if there is perhaps a wider agenda from the Conservatives.”

This is the relevant paragraph taken from his email:

“Since my election in May I have been surprised at the number of my constituents with different mental health issues, so much so I am looking to run a surgery ‘hub’ with a mental health specialist so people can drop in and have their needs assessed and be issued with a form of ‘social prescription’. I recognise many mental health issues are caused or exacerbated by social factors so sometimes a social solution can be more effective than a medical one.

I did a little research.

The 2010 Marmot Review (Fair Society, Healthy Lives) of health inequalities identified social prescribing as an, “approach [that] facilitates greater participation of patients and citizens and support in developing health literacy and improving health and wellbeing”.

It identified additional NHS healthcare costs linked to inequality as being well in excess of £5.5 billion per year. It is claimed that social prescriptions can cut the NHS bill.

However, despite the growing popularity of social prescriptions amongst cash and resource-strapped professionals, the University of York has surprisingly produced research to show that there is little good quality evidence that social prescribing is cost-effective.

But the thing that bothers me the most is the link that the Conservative government have made between social prescriptions, cost-cutting and (as I deeply suspected) as a mechanism of extending behavioural modification (euphemistically called “nudging” by the government’s team of behavioural economists and decision-making “experts”).

I read several current reviews of social precribing, each mentioning both criteria in recommendations for “success.”:

“The work of social prescribing health trainers fits with the approach of the Coalition Government as described in its White Paper on Public Health which emphasises the need to ‘build people’s self esteem and confidence’ in order to bring about changes in behaviour.”

It also fits with the Marmot Review’s recommendation on tackling the social problems that undermine health and with the Coalition Government’s approach to behaviour change as outlined in recent publications such as MINDSPACE.” (Link added by me.)


“In times when finances are under pressure and the NHS is charged with achieving ‘better for less’, primary care needs to be looking at how to do things differently.”

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

Of course, there is what may easily be construed as a whopping self-serving process of linking behavioural change with social prescribing, opening some potentially very lucrative opportunities for Nesta.  

However, taken at face value, the idea of promoting patient participation in their own care sounds very democratic and reasonable. Common sense, in fact.

In this context, social prescribing can be seen as a logical extention of the Biopsychosocial model (BPS) of ill health. The biological component of the model is based on a traditional allopathic (bio-medical) approach to health. The social part of the model investigates how different social factors such as socioeconomic status, culture and poverty impact on health. The psychological component of the biopsychosocial model looks for potential psychological causes for a health problem such as lack of self-control, difficulties with coping, emotional turmoil, and negative thinking.

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

Unum was involved in advising the government on making the devastating cuts to disabled people’s support in the UK’s controversial Welfare Reform Bill. (See also: The influence of the private insurance industry on the UK welfare reforms.)

Secondly, this is a government that tends to emphasise citizen responsibilities over rights, moralising and psychologizing social problems, whilst quietly editing out government responsibilities and democratic obligations towards citizens.

For example, poverty, which is caused by political decisions affecting socioeconomic outcomes, is described by the Conservatives, using elaborate victim-blame narratives, and this is particularly objectionable at a time when inequality has never been greater in the UK. Poverty may only be properly seen in a structural context, including account of the exclusion and oppression experienced by those living in poverty, the global neoliberal order, the gender order, the disability, racial, sexual and other orders which frame social life and precipitate poverty in complex and diverse ways. It’s down to policy-makers to address the structural origins of poverty, not the poor, who are the casualities of politically imposed structural constraints.

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

A government that regards individuals as the architects of their own misfortune tends to formulate policies that act upon individuals to change their behaviour, rather than to address the structural constraints (and meet public needs,) such as social injustice and unequal access to resources. This isn’t a government prepared to meet public needs at all. Instead it’s a government that expects citizens to change their behaviour to accommodate the government’s ideologically directed needs.

That approach flies in the face of established professional community work values and principles.

Poor people suffering mental ill health because we live in a society that is extremely unequal, are blamed by the government for the “symptoms” of their poverty – poor eating habits and “lifestyle choices”. But poverty is all about limited choices, which is itself not a “lifestyle choice.” No-one actually chooses to be poor. Government policies, social structures and systemic failures create poverty.

The Conservatives extend an economic Darwinism, coupled with an extremely intrusive disciplinary approach, mass surveillance and a stigmatising rhetoric, whilst moralising a free-market framework that constrains many and preserves the privilege of a few. The absurdity is this: if an economic framework isn’t meeting the needs of a population, it isn’t an adequate response for the government to act upon citizens who have become casualities of that framework, to persuade or coerce people into fitting within an increasingly harmful and useless socioecomomic ideology.

There is a clear correlation with low socioeconomic status and poor mental health. Poverty is a complex, multidimensional phenomenon, encompassing the lack of means to satisfy basic needs, lack of control over resources, often, a lack of access to education, exclusion from opportunities, and poor health. Poverty is intrinsically alienating and distressing, and of particular concern are the direct and indirect effects of poverty on the development of psychosocial stress. (See also: The Psychological Impact of Austerity – Psychologists Against Austerity.)

State “therapy” aimed at changing the behaviour of individuals diverts attention from growing inequality, and from policies that are creating circumstances of absolute poverty. It also diverts attention from the fact that if people cannot meet their basic physiological needs, they cannot possibly be “incentivised” to meet higher level psychosocial ones. 

I wrote a critical analysis of the government proposal to introduce Cognitive Behaviour Therapists to deliver state “therapy” in job centres earlier this year, with the sole aim of improving “employment outcomes.” There is also an extensive critique of Cognitive Behaviour Therapy (CBT) included in the article, along with some discussion about the merits of community work, which is very relevant to this discussion. (See: The power of positive thinking is really political gaslighting.)

I also wrote earlier this year about how the government has stigmatised and redefined unemployment, problematizing and re-categorising it as an individual psychological disorder. Both articles are very pertinent to this discusion. (See: Stigmatising unemployment: the government has redefined it as a psychological disorders.)

Welfare has been redefined: it is a now a reflecton of a government pre-occupied with assumptions about and modification of the behaviour and character of recipients rather than with the alleviation of poverty and ensuring economic and social wellbeing.

The stigmatisation of people needing benefits is designed purposefully to displace public sympathy for the poor, and to generate moral outrage, which is then used to further justify the steady dismantling of the welfare state.

Many psychosocial problems have arisen because of social conservatism and neoliberalism. The victims of this government’s policies and decision-making are being portrayed as miscreants – as perpetrators of the social problems caused by the government’s decisions.

It’s all too often the case that good ideas are placed in political ideological frameworks, distorted, and are then applied to simply justify and prop up dogma.

Meanwhile, mental health services are facing crisis because of budget cuts by this government, Local Authorities and community services have also been cut to the bone. (See: The cost of the cuts: the impact on local government and poorer communities.) Those with mental health problems are stranded on an ever-shrinking island.

Policy initiatives such as social prescriptions, which focus on how to remediate problems at an individual level, seeing both poverty and mental illness, for example, as simply states of being – rather than dealing with the generative political and economic practices and social relations framework which precipitated that state in the first place, effectively depoliticises political problems leaving people with an internalised state of oppression, disabling them from taking effective action.

The political refusal to permit people to voice their concerns and anxieties in political rather than personal terms further exacerbates sociopolitical marginalisation, low status, it breaks a sense of connectedness with others and wider communities, it reinforces a sense isolation and of personal responsibility for circumstances that are politically constructed and disowned.