Tag: BMA

Sarah Newton lied to parliament and the public about the DWP’s standardised letter to GPs following ‘fit for work’ assessment

newton

Sarah Newton, former minister of state for disabled people. However, it’s very evident that neither she nor her party actually support disabled people. They prefer oppressing them.

Last month and previously, I reported about the controversial issues raised by the Department for Work and Pensions’ standard ESA65B GP’s letter template, which was only relatively recently placed on the government site, following a series of probing Parliamentary Written Questions instigated by Emma Dent Coad, addressed to the minister of state for disabled people. Her responses to the questions were repetitive, vague, unevidenced and did not address the questions raised. 

Campaigners and MPs have called for the Department for Work and Pensions’ (DWP) amended letter to GPs to be scrapped after it emerged that ill and disabled people appealing against unfair work capability assessment (WCA) decisions were left in near destitution after their GPs refused to provide further ‘fit notes’, because they were instructed that they did not need to by DWP officials.

It emerged that ministers ordered changes to the standard-issue letter to remove references that made it clear to GPs they may have to issue a medical statement if their patient wished to appeal against a WCA decision. The DWP claims this was not intended to dissuade GPs from issuing fit notes. 

However, it’s highly unlikely that government ministers ordered the amendment to the letter for another purpose, as there are none. This was a calculated strategy to deter people from appealing DWP decisions, by leaving them in severe financial hardship.

The mandatory review was also introduced for similar reasons, since people are left without any income while the DWP reviews its decision, a process which can take longer than six weeks.  

Those people who challenge WCA decisions are entitled to continue to receive employment and support allowance (ESA) at basic rate, worth £73.10 a week while they await their appeal hearing, but to do so they must obtain fit notes from their GPs to provide evidence that they are too ill to work.

They must also first await the outcome of a mandatory review before submitting their appeal. Before a claimant may lodge an appeal, they must first ask the DWP to ‘reconsider’ their original decision. There is no limit on how long the DWP may take to reconsider the original decision about their award. 

The DWP has a stated target of upholding 80% of their original decisions, so the majority of people then have to appeal following the review outcome, since the . The law says that the claimant may claim basic rate ESA following mandatory review if they wish to proceed with an appeal.

So the misleading change to the template letter routinely sent from the DWP to GPs has led to people who have lodged an appeal against an unfair decision being stopped from claiming basic rate ESA while awaiting the appeal hearing. This prevents many low-income disabled people from accessing any financial support while they wait for months on end to go to tribunal. Furthermore, we know that catastrophically inaccurate decisions following the assessments within the DWP are pretty much the norm. Nationally, 72% of people who appeal against their work capability assessment decision are successful.

Entitlement to ESA pending appeal is enshrined in the ESA Regulations to cover the whole of the period leading up the hearing. It is also possible to have the payment backdated to cover the Mandatory Review waiting period too – it can take over six weeks for the DWP to review their original decision, over which time people are left without welfare support.

ESA pending appeal is not paid automatically – people usually have to ask for it, and must provide fit notes from their GP, presenting these along with their appeal acknowledgment letter from the Tribunal Courts to their local Job Centre. The Job Centre should report back to the DWP who will arrange for ESA pending appeal to be paid.

From last year, then minister for disabled people, Sarah Newton, responded to one of several Written Questions from Emma Dent Coad, saying: “The ESA65B letter is issued to GPs in every case where an Employment and Support Allowance (ESA) claimant has been found ‘fit for work’. This process was built into the IT system as part of the introduction of ESA in October 2008.

That is partly untrue, since the original wording has been amended. 

Newton went on to say: “Following a Ministerial requirement by the Cabinet Secretary, which was endorsed by the Secretary of State for Work and Pensions, the content of the ESA65B letter has been improved in order to explain to GPs the type of support customers can expect to receive from their local Jobcentre, and to ask GPs to encourage customers in their efforts to return to work.” [My emphasis]. 

The decision to change the letter template was made without any scrutiny from or consultation with parliament or the public.

The standard template letter, titled Help us support your patient to return to or start work says: “We assessed [Title] [First name] [Surname] on and decided that [select] is capable of doing some work, but this might not be the same type of work [select] may have done before.

“We know most people are better off in work, so we are encouraging [Title] [First name] [Surname] to find out what type of work [select] may be able to do with [select] health condition or disability through focused support at [select] local Jobcentre Plus.

“In the course of any further consultations with [Title] [First name] [Surname] we hope you will also encourage [select] in [select] efforts to return to, or start, work

“Please do not give [Title] [First name] [Surname] any more fit notes relating to [select] disability/health condition for ESA purposes.

Newton responded to one of several Written Questions from Emma Dent Coad, saying: “The ESA65B letter is issued to GPs in every case where an ESA claimant has been found ‘fit for work’. This process was built into the IT system as part of the introduction of ESA in October 2008. 

“Following a Ministerial requirement by the Cabinet Secretary, which was endorsed by the Secretary of State for Work and Pensions, the content of the ESA65B letter has been improved in order to explain to GPs the type of support customers can expect to receive from their local Jobcentre, and to ask GPs to encourage customers in their efforts to return to work.” [My emphasis]. 

Professor Helen Stokes-Lampard, the chair of the Royal College of GPs (RCGP), said the lack of clarity over when GPs should issue fit notes could put patients’ finances and health at risk. “No GP wants that, and it only serves to threaten the long-standing trust that patients have in their family doctor.”

Until 2017 the standard letter advised GPs that if their patient appealed against the WCA decision they must continue to provide fit notes.

However, on (undisclosed) ministerial orders, the letter now states that GPs “do not need to provide any more fit notes for ESA purposes”. It does not mention the possibility that the patient may appeal, or that a fit note is needed for the patient to obtain ESA payments until the appeal is heard.

Frank Field, the chair of the work and pensions select committee, also raised the issue with Newton back in January. Newton replied that the wording was amended “to make the letter simpler and clearer”, adding that DWP communications were intended to be “clear, understandable and fit for purpose”.

The purpose appears to be to deter people from appealing unfair DWP decisions concerning the loss of their social security disability award.

Field replied that the wording was “not having the desired effect”, and urged her to revise it to make clear ESA claimants on appeal were entitled to fit notes. “This simple step could greatly ease the stress and worry that people who are awaiting an appeal experience.”

Newton told Field: “We are committed to ensuring our communication is clear, which is why the wording of this letter was cleared by both the British Medical Association and the Royal College of General Practitioners (RCGP). However, we will of course consider feedback when revising the letter.”  Newton tends to stick to a script in her responses, though. She told Emma Coad Dent exactly the same thing, almost word for word last year, in her response to a Written Question.

As I commented in a previous article, it was extremely unclear on what basis the RCGP agreed to the new wording as the change was agreed at a DWP stakeholder meeting for which, according to Newton, there are no formal minutes.

Newton confirmed this in the correspondence between herself and Field, as well as in her responses to Emma Coad Dent’s long series of Written Questions on this issue.

Firstly, on 16 May, last year, Newton says: “The Cabinet Secretary first issued the requirement to revise the ESA65B letter in November 2014.

“The wording of the ESA65B was changed to emphasise the benefits of work and to ask GPs to encourage their patients in their efforts to return to some form of work.”

Then, according to Newton: “The British Medical Association and the Royal College of General Practitioners agreed to the revised wording of the ESA65B on 4 August 2016.” 

However, in June last year, she also said, in response to a Written Question from Emma Dent Coad: “DWP’s Legal Service cleared the revised wording on 29 July 2016 and the then Secretary of State for Work and Pensions subsequently authorised the changes.”

Yet when asked in November last year what written evidence her Department holds on the British Medical Association and Royal College of General Practitioners agreement to the revised wording of the ESA65B letters sent to claimants’ GPs when they fail the work capability assessment, she replied: “There is no written evidence relating to the agreement obtained from the British Medical Association and the Royal College of General Practitioners on the revised wording of the ESA65B letter.

“In accordance with the Answer of 30 May 2018 to Question 146987, agreement on the final wording of the ESA65B was obtained via the regular meetings DWP holds with both organisations.” 

She was being conservative with the truth. In other words, she was telling lies.

Following a series of distressing reports about people dying as they await the result of the Personal Independent Payment (PIP) and ESA assessments, the Work and Pensions select Committee has published the Royal College of GPs’ (RCGP) and the British Medical Association’s (BMA) views on DWPs controversial advice to doctors on “Fit Notes” for people awaiting the outcome of an ESA appeal.

The Committee asked both  organisations (PDF PDF 163 KB)Opens in a new window  (PDF PDF 163 KB)Opens in a new window for their input, following DWP’s repeated claims that they had approved the advice, given in a letter (form, ESA65B) to the GPs of people who have been denied ESA after assessment: PIP and ESA Assessments.

The Committee has described the assessment processes for disability/incapacity benefits as “gruelling” and “error-ridden”, potentially forcing claimants into DWP’s “arduous, protracted” reconsideration and appeals process. People who have been denied ESA at the assessment stage, but who are awaiting the results of their appeal are entitled to an “assessment rate” of ESA, in recognition of the hardship they may endure during the potentially lengthy wait for their appeal.

However, in recent months the Committee has been investigating concerns (PDF PDF 1.41 MB)Opens in a new window that the advice DWP is giving to doctors about the system and process is causing confusion, leading directly to people being left without the lifeline income they are entitled to.

I have reported previously that people have died soon after being declared ‘fit for work’ by the DWP, after the Department have contacted a patients’ doctor without notifying  them, telling the GP not to issue any more ‘fit’ notes. 

Comments from RCGP and BMA

The Department has claimed in response to the Committee (PDF PDF 219 KB)Opens in a new windowthat Agreement on the final wording of the revised ESA65B was obtained via the regular meetings DWP holds” with both the British Medical Association and Royal College of GPs”, (PDF PDF 84 KB)Opens in a new window and that the wording is the outcome of “close and extensive working between DWP, BMA and RCGP.” (PDF PDF 165 KB)Opens in a new window

Both medical professionals’ associations’ have now written to the Committee – and in the case of the RCGP, directly to the Secretary of State (PDF PDF 199 KB)Opens in a new window – expressing their concerns about both DWP’s advice to GPs and its characterisation of their approval or endorsement. The RCGPs said:

“Without a fit note from their GP, claimants who are awaiting the outcome of their appeal will not be able to receive ESA. They would therefore have to seek Universal Credit or Jobseekers Allowance, and subsequently try and meet the work-seeking requirements of those benefits, potentially endangering their health in the process. As such the College is deeply concerned about the potential impact of this on doctors and their relationships with potentially vulnerable patients.”

As the BMA describes in its response to the Committee (PDF PDF 164 KB)Opens in a new window:  

“By way of background the BMA attends meetings with the RCGP and the DWP where information is shared with the aim of improving working practices between the DWP and clinicians. While the BMA may act in an advisory capacity it does not have the authority to clear, approve or otherwise sign off any DWP correspondence or policies and would see this as being clearly outside of our remit…At a meeting with the DWP and RCGP a BMA representative was given sight of the ESA65B amended letter. The BMA considers that sight of this letter was for the purposes of information sharing and did not agree or otherwise sign off the content of the letter.”

The Royal College of GPs put the same point to the Committee (PDF PDF 197 KB)Opens in a new window:

We are aware that the Department claims that ‘The British Medical Association and the Royal College of General Practitioners agreed to the revised wording of the ESA65B on 4 August 2016’. However, there is some ambiguity about what was said in the referenced meeting with the DWP. Since the DWP did not keep any written records of what was said at this meeting [as DWP admits in its latest letter to the Committee (PDF PDF 165 KB)Opens in a new window], we are unable to provide further clarity.”

The RCGP statement continues:

“Since these changes were made, significant evidence has come to light about the negative impact that these changes have had in relation to patient care, leading to some patients being denied fit notes by their doctors. We are concerned that the current wording of ESA65B does not sufficiently clearly indicate that there are circumstances in which GPs may need to continue to issue fit notes for their patients. It is essential that communication with GPs is as clear as possible, to uphold the high levels of trust that exist between GPs and their patients. As a minimum we would want to see the wording of the ESA65B letter urgently changed to its previous wording.”  

This means that ministers have once again mislead both parliament and the public in claiming that both medical professional organisations agreed to the wording of a controversial letter which told GPs not to provide benefits officials with proof that seriously ill patients were unfit for work.

I’ve reported on this particular issue more than once, and highlighted the parliamentary dialogue between Newton, who resigned in March, and the DWP, who have said in separate statements that the document wording “was cleared by both the British Medical Association and the Royal College of General Practitioners”.

Both organisations have now dismissed Newton and the DWPs’ claim. In the letter, the BMA,  said that they did not “clear” the wording, they were simply been shown the letter template during a meeting at the DWP.

When the organisation wrote to Frank Field, Pensions select committee, the letter states categorically that: “The BMA considers that sight of this letter was for the purposes of information sharing and did not agree or otherwise sign off the content of the letter.” 

The RCGP has told work and Pensions secretary Amber Rudd  that the letter “does not clearly indicate that there are exceptions to this wording, including if a claimant is appealing against the decision”. 

The Royal College raised fears that vulnerable patients awaiting the outcome of appeals may further harm their health by trying to meet the requirements of other benefits such as Universal Credit or Jobseeker’s Allowance.

However, a DWP spokesperson told me: “We have regular discussions with the BMA and RCGP to ensure we deliver effective support to disabled people and those with health conditions.

“The wording of this letter was discussed as part of these meetings, as both organisations confirm, as was the release of the final letter.

“Of course we recognise the concerns of GPs which is why we are discussing a revised letter with the BMA and RCGP and have issued clear guidance for GPs in the meantime.”

So, not only did the DWP and Conservative ministers lie and get caught out, they have continued to repeat the lie following its exposure.

Meanwhile citizens who are ill and disabled are left in dangerous situations with unacceptable levels of hardship, and some have died as a consequence, yet the government continues to present and mechanically repeat crib sheeted PR and strategic comms responses to limit the political damage of justified concern and criticism of their cruel, miserly, punitive, discriminatory, robotic neoliberalism and authoritarian policies that target those with the least in any way they can to prevent them from accessing the support that their taxes and National Insurance have contributed to creating. 

When David Cameron said the Conservative party was going to address the ‘culture of entitlement’, and ‘change the relationship between citizens and the state’ this is precisely the kind of underhand, targeted discrimination he had in mind. The ‘low tax, low welfare society’ is one where the wealthiest pay very little tax and the poorest citizens – in work and out – simply go without the means of meeting their most fundamental needs. 

The wider political aim is to systematically dismantle every single welfare and public service and to normalise the brutality of this process by almost inscrutable degrees, by telling lies that attempt to neutralise the serious concerns raised by campaigners, opposition MPs, academics, charities and medical professionals. This method of political gaslighting is much worse than lying, because it is a calculated, deliberate method of psychological manipulation and abuse.

 

 


I don’t make any money from my work. But if you like, you can contribute by making a donation which helps me continue to research and write informative, insightful and independent articles, and to provide support to others going through disability  assessment and appeals. The smallest amount is much appreciated – thank you.

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Misleading DWP letter to GPs is depriving disabled people of lifeline support

newton

Credit: PA Images

Last month I reported about the issues raised by the Department for Work and Pensions’ ESA65B GP’s letter template, which was only recently placed on the government site, following a series of Parliamentary Written Questions.

Campaigners and MPs have called for the Department for Work and Pensions (DWP) standard letter to GPs to be scrapped after it emerged that ill and disabled appealing against unfair work capability assessment (WCA) decisions were left in near destitution after their GPs refused to provide further ‘fit notes’, because they were advised they did not need to by DWP officials.

It emerged that ministers ordered changes to the standard-issue letter to remove references that made it clear to GPs they may have to issue a medical statement if their patient wished to appeal against a WCA decision. The DWP claims this was not intended to dissuade GPs from issuing fit notes. 

Those people who challenge WCA decisions are entitled to continue to receive employment and support allowance (ESA) at basic rate, worth £73.10 a week while they await their appeal hearing, but to do so they must obtain fit notes from their GPs to prove they are too ill to work.

They must also await the outcome of a mandatory review.  Before a claimant may lodge an appeal, the must first ask the DWP to ‘reconsider’ their original decision. However, the DWP has a stated target of upholding 80% of their original decisions, so the majority of people then have to appeal following the review outcome. The law says that the claimant may claim basic rate ESA following mandatory review if they wish to proceed with an appeal.

So the misleading change to the template letter routinely sent from the DWP to GPs has led to people who have lodged an appeal against an unfair decision being blocked from claiming ESA while awaiting the appeal hearing. This prevents many low-income disabled people from accessing financial support while they wait for months on end to go to tribunal. Furthermore, we know that catastrophically inaccurate assessments within the DWP are pretty much the norm. Nationally, 72% of people who appeal against their work capability assessment decision are successful.

Entitlement to ESA pending appeal is enshrined in the ESA Regulations to cover the whole of the period leading up the hearing. It is also possible to have the payment backdated to cover the Mandatory Review waiting period too – it can take over six weeks for the DWP to review their original decision, over which time people are left without welfare support.

ESA pending appeal is not paid automatically – people usually have to ask for it, and must provide fit notes from their GP, presenting these along with their appeal acknowledgment letter from the Tribunal Courts to their local Job Centre. The Job Centre should report back to the DWP who will arrange for ESA pending appeal to be paid.

From last year, then minister for disabled people, Sarah Newton, responded to one of several Written Questions from Emma Dent Coad, saying: “The ESA65B letter is issued to GPs in every case where an Employment and Support Allowance (ESA) claimant has been found ‘fit for work’. This process was built into the IT system as part of the introduction of ESA in October 2008. 

“Following a Ministerial requirement by the Cabinet Secretary, which was endorsed by the Secretary of State for Work and Pensions, the content of the ESA65B letter has been improved in order to explain to GPs the type of support customers can expect to receive from their local Jobcentre, and to ask GPs to encourage customers in their efforts to return to work.” [My emphasis]. 

The decision to change the letter template was made without any scrutiny from or consultation with parliament or the public.

The standard letter, titled “Help us support your patient to return to or start work.” says: “We assessed [Title] [First name] [Surname] on and decided that [select] is capable of doing some work, but this might not be the same type of work [select] may have done before.

“We know most people are better off in work, so we are encouraging [Title] [First name] [Surname] to find out what type of work [select] may be able to do with [select] health condition or disability through focused support at [select] local Jobcentre Plus.

“In the course of any further consultations with [Title] [First name] [Surname] we hope you will also encourage [select] in [select] efforts to return to, or start, work

“Please do not give [Title] [First name] [Surname] any more fit notes relating to [select] disability/health condition for ESA purposes.

Minister for disabled people, Sarah Newton, responded to one of several Written Questions from Emma Dent Coad, saying: “The ESA65B letter is issued to GPs in every case where an ESA claimant has been found ‘fit for work’. This process was built into the IT system as part of the introduction of ESA in October 2008. 

“Following a Ministerial requirement by the Cabinet Secretary, which was endorsed by the Secretary of State for Work and Pensions, the content of the ESA65B letter has been improved in order to explain to GPs the type of support customers can expect to receive from their local Jobcentre, and to ask GPs to encourage customers in their efforts to return to work.” [My emphasis]. 

Professor Helen Stokes-Lampard, the chair of the Royal College of GPs (RCGP), said the lack of clarity over when GPs should issue fit notes could put patients’ finances and health at risk. “No GP wants that, and it only serves to threaten the long-standing trust that patients have in their family doctor.”

Until 2017 the standard letter advised GPs that if their patient appealed against the WCA decision they must continue to provide fit notes.

However, on (undisclosed) ministerial orders, the letter now states that GPs “do not need to provide any more fit notes for ESA purposes”. It does not mention the possibility that the patient may appeal, or that a fit note is needed for the patient to obtain ESA payments until the appeal is heard.

Frank Field, the chair of the work and pensions select committee, has also raised the issue with the then disability minister Sarah Newton back in January. Newton replied that the wording was amended “to make the letter simpler and clearer”, adding that DWP communications were intended to be “clear, understandable and fit for purpose”.

Field replied that the wording was “not having the desired effect”, and urged her to revise it to make clear ESA claimants on appeal were entitled to fit notes. “This simple step could greatly ease the stress and worry that people who are awaiting an appeal experience.”

A DWP spokesperson said: “These letters simply inform GPs when a claimant has been found fit for work and are not intended to dissuade them from issuing fit notes for ESA appeal purposes, to claim otherwise is inaccurate.”

However, there is a hint the letter may be changed. Newton told Field: “We are committed to ensuring our communication is clear, which is why the wording of this letter was cleared by both the British Medical Association and the Royal College of General Practitioners (RCGP). However, we will of course consider feedback when revising the letter.”  Newton tends to stick to a script in her responses, though. She told Emma Coad Dent exactly the same thing, almost word for word last year, in her response to a Written Question.

It remains very unclear on what basis the RCGP agreed to the new wording as the change was agreed at a DWP stakeholder meeting for which, according to Newton, there are no formal minutes. Newton confirmed this in the correspondence between herself and Field, as well as in her responses to Emma Coad Dent’s long series of Written Questions on this issue.

Firstly, on 16 May, last year, Newton says: “The Cabinet Secretary first issued the requirement to revise the ESA65B letter in November 2014.

“The wording of the ESA65B was changed to emphasise the benefits of work and to ask GPs to encourage their patients in their efforts to return to some form of work.”

Then, according to Newton: “The British Medical Association and the Royal College of General Practitioners agreed to the revised wording of the ESA65B on 4 August 2016.” 

However, in June last year, she also said, in response to a Written Question from Emma Dent Coad: “DWP’s Legal Service cleared the revised wording on 29 July 2016 and the then Secretary of State for Work and Pensions subsequently authorised the changes.”

Yet when asked in November last year what written evidence her Department holds on the British Medical Association and Royal College of General Practitioners agreement to the revised wording of the ESA65B letters sent to claimants’ GPs when they fail the work capability assessment, she replied: “There is no written evidence relating to the agreement obtained from the British Medical Association and the Royal College of General Practitioners on the revised wording of the ESA65B letter.

“In accordance with the Answer of 30 May 2018 to Question 146987, agreement on the final wording of the ESA65B was obtained via the regular meetings DWP holds with both organisations.” 

Newton had previously also said: “In accordance with the Answer of 3 July 2018 to Question 155402, the information is not available as there is no written minute of the meeting between officials from this Department and representatives from the British Medical Association and the Royal College of General Practitioners on the revised wording of the ESA65B letter.” 

In June last year, Dent Coad asked Newton who attended the meetings between officials in her Department and the (a) British Medical Association and (b) Royal College of General Practitioners on the revised wording of the ESA65B; and if she would place in the Library a copy of the minutes of those meetings. Newton responded on 03 July 2018:  

“The names of the participants representing the British Medical Association and the Royal College of General Practitioners who attended the meetings referred to constitute their personal data and in accordance with data protection principles, they will not be disclosed without informed consent. DWP officials did not take minutes of these meetings.”

And: “No other external stakeholders were consulted on the development of the revised ESA65B letter.”

Newton has also said in response to Written Questions: “The Department is committed to ensuring all of its communications are clear, accurate and understandable and we continuously improve our letters. We engage regularly with the welfare benefits advice sector and disability charities and take into account all of the feedback we receive.”

“We have received comments from a number of sources including MPs, stakeholder organisations and GPs on the current version of the ESA65B letter and will take all of their feedback into account when revising it.”

I should hope so. 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.

 

Related

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

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

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

 


 

I don’t make any money from my work. I’m disabled through illness and on a very low income. But you can make a donation to help me continue to research and write free, informative, insightful and independent articles, and to provide support to others going through Universal Credit, PIP and ESA assessment, mandatory review and appeal. The smallest amount is much appreciated – thank you.

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British Medical Association proposals deemed passive ‘euthanasia by stealth’ for disabled people with degenerative illnesses

Image result for euthanasia 

The British Medical Association have put forward proposals in response to legal test cases in which judges ruled that qualified NHS staff and officials no longer required a court’s permission to withdraw artificial nutrition and hydration from those patients who are incapacitated and unable to communicate or feed themselves.

The Supreme Court justices’ decision in July supported the right of doctors to withdraw life-sustaining nutrition on their own authority, provided they had the explicit permission of the patient’s family or, where no family existed, medical proxy. If there is a disagreement and the decision is finely balanced, an application should still be made to the Court Of Protection. 

The Court of Protection is the specialist court for all issues relating to people who lack capacity to make specific decisions. The court can make decisions and appoint deputies to make decisions about someone’s property and financial affairs or their healthcare and personal welfare.

Under the Mental Capacity Act 2005 (which is also currently being re-written by the government), the court has the power to:

• make decisions about the personal welfare or property and financial affairs of people who lack the capacity to make such decisions themselves;
• make declarations about a person’s capacity to make a decision;
• make decisions in relation to serious medical treatment cases, which relate to providing, withdrawing or withholding treatment to a person who lacks capacity;
• authorise deprivation of liberty in relation to a person’s care and residence arrangements;
• appoint a deputy to make ongoing decisions on behalf of a person who lacks capacity, in relation to either the person’s personal welfare or property and financial affairs; and
• make decisions about a Lasting Power of Attorney or Enduring Power of Attorney, including whether the power is valid, objections to registration, the scope of the  attorney’s powers and the removal of attorney’s powers

According to the draft proposals currently being circulated by the British Medical Association (BMA), doctors should be granted the authority to end the lives not only of those patients who are near death or in vegetative or minimally conscious states but also “the much larger group of patients who have multiple co-morbidities, frailty or degenerative neurological conditions.”  

This also includes stroke patients and those with “rapidly progressing brain injury.”   

However, on the NHS site, it says: “In most cases, a minimally conscious state isn’t usually considered to be permanent until it’s lasted several years. 

“It’s impossible to predict the chances of someone in a state of impaired consciousness improving.” 

“Supportive treatment is used to give the best chance of natural improvement. 

“This can involve:

  • providing nutrition through a feeding tube 
  • making sure the person is moved regularly so they don’t develop pressure ulcers
  • gently exercising their joints to prevent them becoming tight
  • keeping their skin clean
  • managing their bowel and bladder (for example, using a tube known as a catheter to drain the bladder)
  • keeping their teeth and mouth clean
  • offering opportunities for periods of meaningful activity – such as listening to music or watching television, being shown pictures or hearing family members talking.” 

And importantly: “It’s impossible to predict the chances of someone in a state of impaired consciousness improving.”

The authors of the BMA document say: “Due to the degenerative nature of their condition, these patients are on an expected downward trajectory and will inevitably die, usually as a result of their underlying condition, although perhaps not imminently and could, potentially, go on living for many years.”

In the Executive Summary of the BMA document, it says that no second opinion need be obtained unless there is ‘reasonable doubt about the diagnosis or prognosis, or where the healthcare team has limited experience of the condition in question’ [ …] ‘it is not necessary to wait until (investigations) have been completed’ if there is not ‘sufficient evidence’ that they will ‘affect the outcome of the best interests assessment’ 

Nutrition and hydration delivered by tubes is currently legally defined as ‘medical treatment’ and not ‘basic ‘care’.  

There have been a number of legal developments that change the way such decisions about life-prolonging treatments are made, in addition to the recent court judgments and the government’s radical withdrawal of the Court of Protection’s Practice Direction 9E which addresses protections concerning serious medical treatment.

The direction was effectively abolished by the Ministry of Justice  and the changes came into effect last December. The Court of Protection in English law is a superior court of record created under the Mental Capacity Act 2005. It has jurisdiction over the property, financial affairs and personal welfare of people who lack mental capacity to make decisions for themselves. 

As the changes to protections were introduced via secondary legislation – a negative resolution statutory instrument – there was very little parliamentary scrutiny. Furthermore, as the instrument is subject to negative resolution procedure no statement regarding implications in relation to the European Convention on Human Rights was required from government ministers, nor was public consultation deemed necessary. An Impact Assessment has not been prepared for this instrument. 

The fact that the UK government had already made amendments to safeguarding laws to accommodate these proposals, which took effect last December, and now plan to make it easier to remove people’s liberty under the Mental Health Act without public consultation, has caused deep unease. In the latest proposed changes to the Mental Health Act, the government seems to think it is appropriate to consider restrictions of people’s liberties as part of their overall ‘care package.’

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The Law Society has issued a rather damning briefing on the Mental Capacity (Amendment) Bill 2018 that moved to a Lords committee stage, early last month.

In their briefing, the society say: “While agreeing that simplification is needed and acknowledging that there are resource constraints, these constraints are “insufficient justification for not implementing fully the safeguards recommended by the Law Commission.” 

It is in light of the most recent change in legislation that the British Medical Association (BMA) put forward  proposals that mean doctors may be permitted to end the lives of patients who may otherwise have survived for years, by the withdrawal of nutrition and hydration, without the need to go to court. While this reduces substantial cost to the NHS in terms of legal fees and in the prolonged treatment for some patients, not everyone is comfortable with these developments.

Writing critically about the legislation changes last year, Mohamed Y Rady and Joseph L. Verheijde say:

“(1) starvation and dehydration is certain to cause death without the presence of concurrent life-limiting disease or life-threatening illness and (2) the dying process by starvation and dehydration can last two to three weeks and can be distressful to both patients and their families. We disagree with the legal and clinical stipulation (post-Bland [a legal case]) that assisted nutrition and hydration (ANH) is medical treatment. Instead, as adopted in many other jurisdictions, we hold that ANH constitutes ‘a basic compassionate care service rendered to disabled persons’. 

“We think that court oversight is of practical importance for the safety of the general public and the protection of vulnerable disabled persons in society.

“We outline our rationale for advocating that court oversight should not be limited to Vegative State/Minimal Conscious State but should include any person.”

The authors added:  “The clinical guidelines have distinguished only three levels of disorders of consciousness (DOC) (coma, Vegative State (VG), and Minimal Conscious State (MCS) based on clinical assessment for the presence or absence of awareness and wakefulness. However, the diagnostic accuracy of the guidelines’ criteria and definitions of the three levels of DOC has not been validated scientifically. Cohort studies suggest that the rate of clinical misdiagnosis in VS is at least 41% and this error rate has not declined over the past 15 years.

“Incorrect diagnosis can result in a fatal outcome because of premature withdrawal of medical care and ANH. The clinical guidelines have not yet acknowledged the relevance of contemporary neuroscience advances to increase the diagnostic accuracy and expand on the available therapeutic options in DOC. Incorrect diagnosis and/or withholding of therapy in DOC violates the trust of families in the transparency and truthfulness of clinicians who are making life and death decisions on behalf of their loved ones.

“The clinical guidelines have recommended that a neurological diagnosis and prognosis should be made at least within four weeks after the onset of prolonged DOC to determine futility of continued medical care and ANH (Royal College of Physicians of London. Under these circumstances, we propose that court oversight can provide an additional safeguard by including independent neuroscience experts to confirm the clinical diagnosis and prognosis of DOC and to ensure that the decision-making processes are well-informed and as rigorous as possible. Life and death decisions in DOC should be supported by contemporary neuroscience, among other considerations, and not be based on outdated clinical guidelines.”

In summary, the authors propose that until such time as we have greater clarity and understanding about the disorders of consciousness, and about the legal and ethical principles to be applied, there remains a need for independent oversight and that applications to the court should continue to be obligatory in all cases where the withdrawal of ANH is proposed, at least for the time being.

Their paper can be read in full here.

The BMA proposals to withdraw nutrition and hydration tubes have also been condemned as ‘euthanasia by stealth’.

Dr Peter Saunders, from the group Care Not Killing, said: “This is a recipe for euthanasia by stealth, but all in the name of autonomy and best interests – the very worst kind of doctor paternalism justified on the grounds that the patient would have wanted it.

“There are conceivably tens of thousands of patients in England and Wales who are vulnerable to the use and abuse of this guidance.

“It will be almost impossible to work out what has happened in a given case and there are no legal mechanisms in place for bringing abusers to justice.”

The landmark Bland ruling set down that artificial nutrition and hydration by tube are not normal feeding but ‘medical treatment’. It also said that it might not be in a patient’s best interests to be treated, and if medical treatment is not in the best interests of a patient who cannot speak for themselves, it can be stopped. Tony Bland, a Liverpool football supporter was just twenty-two when he suffered severe brain damage in the crush at Hillsborough football stadium in April 1989. The court ruled that he should be allowed to die.

The BMA document was circulated, however, in June. This follows after a court ruling in 2017, which concluded that there was no requirement for court approval before removing patients’ nutrition and hydration tubes.

More recently in July, the country’s highest appeal court, the Supreme Court, ruled in the test case of a patient known only as ‘Y’ that doctors can decide a patient should die without reference to a court.

A spokesman for the BMA said that decisions surrounding the withdrawal of clinically assisted nutrition and hydration (CANH) presented “clinical, ethical and legal challenges.” 

He added: “Following a number of legal developments, the BMA has been working with the Royal College of Physicians and the General Medical Council to produce guidance on best practice for health professionals when facing decisions about CANH.

“CANH is a form of medical treatment. The aim of medical treatment is not simply to prolong life at all costs, and the courts have been clear that in some circumstances it will not be in the best interests of the individual patients to receive it.

“Those making these decisions must do so in full dialogue with families to determine what is right for the individual patient, and of course, when there is any disagreement the court still has an important role to play.”

These proposals come at a time when health care has been subjected to increasing rationing. 

The BMA document says that the decisions on removing nutrition and hydration tubes should be taken by consultants for hospital patients, or GPs for those in nursing or residential homes or living in their own homes. It was suggested that families or friends should be consulted, usually through ‘best interests meetings’ set up to decide whether it would be better for a patient to live or die. However, the BMA suggested that family and friends should not have the final say on the matter.

In the Executive Summary, the BMA say that no second opinion need be obtained unless there is ‘reasonable doubt about the diagnosis or prognosis, or where the healthcare team has limited experience of the condition in question’ [ …] ‘it is not necessary to wait until (investigations) have been completed’ if there is not ‘sufficient evidence’ that they will ‘affect the outcome of the best interests assessment’ 

Shockingly, the BMA also propose that when patients die after the withdrawal of nutrition and hydration tubes, this should not be mentioned on death certificates. Instead only the underlying original condition should be given.

Professor Patrick Pullicino, from East Kent Hospitals University NHS Trust, said that this directs doctors to falsify death certificates. It tells doctors to put down the pre-existing condition and not that they died of dehydration. It will totally conceal the statistics of patients who are being dehydrated to death.”

Understandably, doctors and campaigners who are opposed to euthanasia and the deliberate termination of life by medical staff have condemned the proposals.

Pullicino, who is the consultant that helped expose the controversial hospital deaths under the discredited Liverpool Care Pathway, said the BMA plan was ‘terrible’. 

He added: “It codifies current practices of withdrawing food and fluid at the end of life and thereby encourages it.

“It facilitates the extension of end-of-life pathways to people with neurological diseases who are not dying, which is a very negative thing because there are a lot of disabled neurological patients.

“It perpetuates the myth of ‘best interests’, which has been shown to be erroneous and reflective of members’ views and not of the real best interests of the patients.”

I agree. My inital thoughts are that we need to guarantee people with disabilities have access to high quality palliative care. We need to have a process which reviews every incidence of proposed euthanasia, and that panel needs to include people with disabilities. We need to ensure that family members and service providers or anyone else who will benefit financially cannot abuse any application for end of life withdrawal of clinically assisted nutrition and hydration.

We also need to ensure the absolute transparency and accountability of decision-makers, which must include an accurate and honest record of cause of death on death certificates. Coroners have a duty to prevent future deaths, where medical mistakes have been made.

There is no clear definition of ‘degenerative diseases’ in the BMA document. Some illnesses, such as multiple sclerosis, lupus and other autoimmune mediated diseases, for example, may be progressive. Several of these illnesses may affect the neurological system. Most of the treatments for this group of disorders are experimental. People can improve over time, with or without some treatments, following periods of being critical ill. Many of the treatments are only prescribed as a last resort, as they are prohibitively expensive (biologics in particular) especially at a time of heavy NHS funding cuts. The outcomes of these diseases are widely variable from one person to the next. People may have indefinite remissions after years of being seriously ill. 

Even if these types of disease are not currently included in the BMA guidelines, complications or co-morbidities and frailty arising over the course of an illness may be.  

What guarantee do we have that the categories won’t expand over time?

The legislative changes have been couched in terms of ‘saving money’. The purpose of the NHS is to save lives. Everyone has the basic right to life, that must not be contingent on the ideological preferences of a ‘small state’ neoliberal government. ‘Best interests’ are not an political category, nor are they open to ideological interpretation. 

The UK government’s brand of ideological paternalism towards poor people claiming welfare support, for example, involves the removal of the means of meeting basic survival needs as a punishment in the form of sanctions, also considered to be in people’s ‘best interests’.

Unemployment itself has been redefined as a psychological or character disorder over the last few years, and the welfare state has become a political environment for administering discipline, which has shifted it away from the original purpose of providing basic support and alleviating poverty. Behavioural economics has contributed to bolstering this perspective by pathologising people who need support from publicly funded public services via claims of ‘cognitive deficits’ of poor people, rather than acknowledging the structural explanations of poverty.  Perish the thought that a socioeconomic system founded on competition would foster inequality. 

In healthcare there has been a shift towards ‘behavioural medicine’ too, apparent in the controversial PACE trial and a general emphasis on people’s ‘lifestyle choices,’ and personal responsibility. However these are extremely overly simplistic ideolological narratives that have not emerged because of robust empirical evidence. Public services were not originally designed to punish poor people who need them. Yet the withdrawal of the means of citizens meeting their basic survival needs seems to have become normalised. Pathologising and punishing people who need the support of public services has somehow become acceptable. 

The increasing rationing of treatments within the NHS and the neoliberal logic underpinning this is also a cause for concern. People who need support from any public service are subjected to increasing conditionality and rationing in an era of neoliberal austerity.

A spokesman for the BMA said that decisions surrounding the withdrawal of clinically assisted nutrition and hydration (CANH) presented “clinical, ethical and legal challenges.” 

He added: “Following a number of legal developments, the BMA has been working with the Royal College of Physicians and the General Medical Council to produce guidance on best practice for health professionals when facing decisions about CANH.

“CANH is a form of medical treatment. The aim of medical treatment is not simply to prolong life at all costs, and the courts have been clear that in some circumstances it will not be in the best interests of the individual patients to receive it.

Those making these decisions must do so in full dialogue with families to determine what is right for the individual patient, and of course, when there is any disagreement the court still has an important role to play.

“We shared the draft guidance in confidence with legal and health professionals and organisations and patient support groups to seek their views. The final version will reflect last month’s Supreme Court judgment when it is published this year.” 

The guidance says it is based on the current legal position which it defines as follows:

  • Clinically assisted nutrition and hydration (CANH) – essentially food and fluids by a fine tube through the nose or through the skin into the stomach – is a form of medical treatment
  • Treatment should only be provided when it is in a patient’s ‘best interests’
  • Decision makers should start from the presumption that it is in a patient’s best interests to receive life-sustaining treatment but that presumption may be overturned in individual cases
  • All decisions should be made in accordance with the Mental Capacity Act 2005 (which the government is proposing to amend).

The 77-page ‘confidential’ document, which is currently out for ‘consultation’ (although only to a few selected individuals), has been prepared by the BMA in conjunction with the Royal College of Physicians (RCP) and the doctors’ regulatory authority, the General Medical Council (GMC). It will not be open for public consultation at any point before publication later in the autumn.

The draft guidance, which builds on case and statute law and on previous practice guidelines, has huge implications for the care of some of the most vulnerable people in England and Wales.

However, it does not permit assisted dying – which is when a patient wants to end their life. British parliaments have consistently refused to legalise active euthanasia or assisted suicide for people with a quality of life they would not find ‘acceptable’ or would not ‘have wanted’. The BMA is proposing that doctors, not patients should make the choice to end a life, and that to end lives by starvation and dehydration, rather than with a lethal injection, is somehow perfectly acceptable.

So acceptable in fact that the BMA propose starvation and dehydration or withdrawal of care (or treatment if you wish) should be left off the death certificate, suggesting instead that the ‘underlying medical condition’ should be recorded as the cause of death. This suggestion does not inspire confidence in transparency and accountability concerning such fundamentally irreversible medical decisions, since the record of death hides errors in judgment and diagnoses, prevents scrutiny and prevents coroners from fulfilling the mandatory obligation to ‘prevent future deaths’ in the case of medical incompetence, negligence, abuse, deceit and error.

 


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

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

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

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

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

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

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

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

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

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

How does this address the “disability employment gap”? 

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

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

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

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

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

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

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

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

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

Work is not a “health” outcome

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

A Department for Work and Pensions research document published back in 2011 – Routes onto Employment and Support Allowance – said that if people believed that work was good for them, they were less likely to claim or stay on disability benefits.

It was decided that people should be “encouraged” to believe that work was “good” for health. There is no empirical basis for the belief, and the purpose of encouraging it is simply to cut the numbers of disabled people claiming ESA by “encouraging” them into work. Some people’s work is undoubtedly a source of wellbeing and provides a sense of purpose. That is not the same thing as being “good for health”.

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

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

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

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

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

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

The government made a political and a particularly partisan decision, rather than one that has any an evidence base, to promote the cost-cutting and unverified, irrational belief that work is a “health” outcome.

Furthermore, the research does conclude that health status itself is the greatest determinant in whether or not people return to work. That means that those not in work are not recovered and have longer term health problems that tend not to get better.

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

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

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

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

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

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

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

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

This is psychopolitics. It’s all about (re)defining the experience and reality of a social group to justify dismantling public services (especially welfare), and that is form of gaslighting intended to extend oppressive political control and micromanagement. In linking receipt of welfare with health services and “state therapy,” with the single intended outcome explicitly expressed as employment, the government is purposefully conflating citizen’s widely varied needs with economic outcomes and diktats, isolating people from traditionally non-partisan networks of relatively unconditional support, such as the health service, social services, community services and mental health services.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Image result for work coaches : you can still work if you are ill UK
Source: Work, health and disability green paper: improving lives. Consultation outcome


Last year I wrote a critical article about the government’s new
Work and Health Programme, I flagged up concerns regarding government plans to enlist GPs in prescribing work coaches for people who are sick and disabled, and in providing advice on job-seeking. The private and confidential patient-doctor relationship ought to be about addressing medical health problems, and supporting people who are ill, not about creating yet another space for an over extension of the coercive arm of the state to “help people into work”, regardless of whether or not they are actually well enough to cope with working.

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

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

I discovered last October, almost by chance, that the Nudge Unit team have been working with the Department for Work and Pensions and the Department of Health to trial social experiments aimed at finding ways of: “preventing people from falling out of the jobs market and going onto Employment and Support Allowance (ESA).”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You can:

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

Opt out letter (PDF)

Opt out letter (MS Word)

Opt out letter (Rich Text)

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

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

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

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

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

It’s hardly the case that the state has an even remotely credible track record of assessing people’s medical conditions, nor is it the case that this government bothers itself with empirical evidence, or deigns to listen to concerns raised by citizens, academics, professionals and charities regarding the harm that their policies are causing. This is a government that can’t even manage to observe basic human rights, let alone care about citizen’s best interests, health and wellbeing.

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

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

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

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

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


Illustration by Jack Hudson

The government’s Nudge Unit team is currently 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.”

This is a crass state intrusion on the private and confidential patient-doctor relationship, which ought to be about addressing medical health problems, and supporting people who are ill, not about creating yet another space for obsessive political micromanagement. It’s yet another overextension of the coercive arm of the state to “help” people into work. Furthermore, this move will inevitably distort people’s interactions with their doctors: it will undermine the trust and rapport that the doctor-patient relationship is founded on.

In the current political context, where the government extends a brutally disciplinarian approach to basic social security entitlement, it’s very difficult to see how the plans to place employees from the Department for Work and Pensions in GP practices can be seen as anything but a threatening gesture towards patients who are ill, and who were, up until recent years, quite rightly exempted from working. Now it seems that this group, which includes some of our most vulnerable citizens, are being politically bullied and coerced into working, regardless of the consequences for their health and wellbeing.

Of course the government haven’t announced this latest “intervention” in the lives of disabled people. I found out about it quite by chance because I read Matthew Hancock’s recent conference speech: The Future of Public Services.

I researched a little further and found an article in Pulse which confirmed Hancock’s comment: GP practices to provide advice on job seeking in new pilot scheme.

Hancock is appointed Minister for the Cabinet Office and Paymaster General, and was previously the Minister of State for Business and Enterprise. He headed David Cameron’s “earn or learn” taskforce which aims to have every young person earning or “learning” from April 2017.

He announced that 18 to 21-year-olds who can’t find work would be required to do work experience (free labour for Tory business donors) as well as looking for jobs or face losing their benefits. But then Hancock is keen to commodify everyone and everything, including public data.

However his references to “accountability and transparency” don’t stand up to much scrutiny when we consider the fact that he recently laid a statement before parliament outlining details about the five-person commission that will be asked to decide whether the Freedom of Information act is too expensive and “overly intrusive.”

He goes on to say: “And this brings me onto my second area of reform: experimentation. Because in seeking to improve our services, we need to know what actually works.”

But we need to ask for whom services are being “improved” and for whom does such reform work, exactly?

And did any of the public actually consent to being experimented upon by the state?

Or to having their behaviour modified without their knowledge?

Now that the nudge unit has been privatised, it is protected from public scrutiny, and worryingly, it is also no longer subject to the accountability afforded the public by the Freedom of Information Act.

The Tory welfare “reforms” are a big business profiteering opportunity, whilst lifeline benefits are being steadily withdrawn: policy context

The current frame of reference regarding Conservative welfare policies is an authoritarian and punitive one. It’s inconceivable that a government proposing to continue cutting the lifeline income of sick and disabled people, including a further £120 a month to those people in the ESA Work Related Activity group (WRAG), will suddenly show an interest in actually supporting disabled people. There are also proposals to further limit eligibility for Personal Independence Payments (PIP) for sick and disabled people. 

From the shrinking category of legitimate “disability” to forcing people to work for no pay on exploitative workfare schemes, “nudge” has been used to euphemistically frame punitive policies, “applying the principles of behavioural economics to the important issue of the transition from welfare to work.” (From: Employing BELIEF: Applying behavioural economics to welfare to work, 2010.)

And guess who sponsored the “research” into “nudging” people into workfare? Steve Moore, Business Development Director from esg, which is a leading welfare to work and vocational skills group, created through the merger and acquisition of four leading providers in the DWP and LSC sector.” How surprising.

It’s even more unsurprising that esg was established by two Conservative donors with very close ties to ministers, and were subsequently awarded very lucrative contracts with the Department for Work and Pensions. I think there may have been a “cognitive bias” in operation there, too. But who is nudging the nudgers?

Of course the “aim” of the “research” is: “breaking the cycle of benefit dependency especially for our hardest to help customers, including the “cohort” of disabled people.”

However, there’s no such thing as a “cycle of benefit dependency”, it’s a traditional Tory prejudice and is based on historically unevidenced myths. Poverty arises because of socioeconomic circumstances that are unmitigated through government decision-making. In fact this government has intentionally extended and perpetuated inequality through its policies.

2020health – Working Together is a report from 2012 that promotes the absurd notion of work as a health outcome.  This is a central theme amongst ideas that are driving the fit for work and the work and health and programme. Developing this idea further, Dame Carol Black and David Frost’s Health at Work – an independent review of sickness absence was aimed at reviewing ways of “reducing the cost of sickness to employers, ‘taxpayers’ and the economy.” Seems that the central aim of the review wasn’t a genuine focus on sick and disabled people’s wellbeing and “health outcomes,” then. Black and Frost advocated changing sickness certification to further reduce the influence of GPs in “deciding entitlement to out-of-work sickness benefits.”

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

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

The idea that work is a “health” outcome is founded on an absurd and circular Conservative logic that people in work are healthier than those out of work. It’s true that they are, however, the government have yet again confused causes with effects. Work does not make people healthier: it’s simply that healthy people can work and do. People who have long term or chronic illnesses often can’t work. The government’s main objection to sick leave and illness more generally, is that it costs businesses money. As inconvenient as that may be, politically and economically, it isn’t ever going to be possible to cure people of serious illnesses by cruelly coercing them into work.

The government’s removal of essential in-work support for disabled people – such as the Independent Living Fund, and the replacing of Disability Living Allowance  with Personal Independence Payment in order to reduce eligibility, cut costs and “target” support to those most severely disabled, and the cuts to the Access To Work scheme – means that it is now much more difficult for those disabled people who want to work to find suitable and supported employment.

The politics of punishment

There’s a clear connection between the Nudge Unit’s obsession with manipulating “cognitive bias” – in particular, “loss aversion” – and the increased use, extended scope and severity of sanctions, though most people succumbing to the Nudge Unit’s guru effect (ironically, another cognitive bias) think that “nudging” is just about prompting men to pee on the right spot in urinals, or persuading us to donate organs and to pay our taxes on time.

When it comes to technocratic fads like nudge, it’s worth bearing in mind that truth and ethics quite often have an inversely proportional relationship with the profit motive.

For anyone curious as to how such tyrannical behaviour modification techniques like benefit sanctions arose from the bland language, inane, managementspeak acronyms and pseudo-scientific framework of “paternal libertarianism” – nudge – read this paper, focused almost exclusively on New Right obsessions, paying particular attention to the part about “loss aversion” (a cognitive bias according to behavioural economists) on page 7.

And this on page 18: The most obvious policy implication arising from loss aversion is that if policy-makers can clearly convey the losses that certain behaviour will incur, it may encourage people not to do it,” and page 46: “Given that, for most people, losses are more important than comparable gains, it is important that potential losses are defined and made explicit to jobseekers (e.g.the sanctions regime).” 

The recommendation on that page: We believe the regime is currently too complex and, despite people’s tendency towards loss aversion, the lack of clarity around the sanctions regime can make it ineffective. Complexity prevents claimants from fully appreciating the financial losses they face if they do not comply with the conditions of their benefit.”

The Conservatives duly “simplified” sanctions by extending them in terms of severity, frequency and by broadening the scope of their application to include previously protected social groups.

The paper was written in November 2010, prior to the Coalition policy of increased “conditionality” and extended sanctions element of the Tory-led welfare “reforms” in 2012.

Sanctioning welfare recipients by removing their lifeline benefit – originally calculated to meet the cost of only basic survival needs – food, fuel and shelter – isn’t about “arranging choice architecture”, it’s not nudging: it’s operant conditioning. It’s a brand of particularly dystopic, psychopolitical neobehaviourism, and is all about a totalitarian level of micromanaging people to ensure they are obedient and conform to meet the needs of the “choice architects” and policy-makers.

Nudge even permeates language, prompting semantic shifts towards bland descriptors which mask power and class relations, coercive state actions and political intentions. One only need to look at the context in which the government use words like “fair”, “support”, “help” “justice” and “reform” to recognise linguistic behaviourism in action. Or if you prefer, Orwellian doublespeak.

It’s rather difficult to see how starving people and threatening them with destitution can possibly improve the well-being of many socially excluded people, and help to bring them to inclusion.”

The conclusion that Ancel Keys drew from the Minnesota Starvation Experiment in the the US during the 1940s, (which explored the physical and psychological effects of undernutrition, and stressed the dramatic, adverse effect that starvation had on competence, motivation, behaviour, mental attitude and personality) was that “democracy and nation building would not be possible in a population that did not have access to sufficient food.”

No amount of bland and meaningless psychobabble or intransigent, ideologically-tainted policies can legitimize the economic sanctioning of people who are already poor and in need of financial assistance.

Apparently, citizenship and entitlement to basic rights and autonomy is a status conferred on only the currently economically productive. Previous employment and contributions don’t count as “responsibility,” and don’t earn you any rights – the government believes that citizens owe a perpetual debt of unconditional service to the Conservative’s steeply stratified economy. Not much of a social contract, then. Cameron says he wants to “build a responsible society” by removing people’s rights and reducing or removing their lifeline income. Presumably, free invisible bootstraps are part of the deal.

Government decision-making has contributed the most significant influence on “health outcomes.” Conservative policies have entailed a vicious cutting back of support and a reduction of essential provision for sick and disabled people. In fact this group have been disproportionately targeted for austerity cuts time and time again, massively reducing their lifeline income. It’s not being “workless” that has a detrimental impact on people’s health and wellbeing: it is the deliberate impoverishment of those requiring state aid and support, funded from the public purse, (including contributions from those who now need support), which is being dogmatically and steadily withdrawn.

Making work pay for whom?

If work truly paid, then there would be no need to incentivise” almost 1.2 million low-paid workers claiming the new universal credit with the threat of in-work benefit sanctions if they fail to “take steps to boost their earnings.”

It’s very difficult to see how punishing individuals for perhaps being too ill to work more that a few hours, or those working for low pay or part-time in the context of a chronically weak labour market, depressed wages and with little scope for effective negotiating and collective bargaining can possibly be justified. It’s an utterly barbaric way for a government to treat citizens.

Surely if the government was genuinely seeking to increase choices and to widen access to the workplace for sick and disabled people, it would not be cutting the very programmes supporting and extending this aim, such as the Access to Work scheme  – a fund that helps people and employers to cover the extra living costs arising due to disabilities that might present barriers to work – and the Independent Living Fund.

This government has pushed at the public’s rational and moral boundaries, establishing and attempting to justify a draconian trend of punishing those unable to work, and what was previously unthinkable – stigmatising and punishing legally protected social groups such as sick and disabled people – has become somehow acceptable. We are on a very slippery slope, clearly mapped out previously by Allport’s scale of prejudice.

People’s needs don’t disappear just because the government has decided to “pay down” an ever-growing debt and build a “surplus” by taking money from those that have the least. Or because the government doesn’t like “big state interventions.”

So the recent proposed cut to ESA – and this is a group of sick and disabled people deemed physically incapable of work by doctors – is completely unjustified and unjustifiable. No amount of pseudo-psychology and paternalist cruelty can motivate or “incentivise” people who are medically ill.

It’s for disabled individuals and their doctors – professionals, specialists and experts – to decide if a person can work or not, it’s not the role of the state, motivated only by a perverse economic Darwinist ideology. Maslow taught us that we must attend to our physiological needs before we may be motivated to meet higher level psychosocial ones.

Iain Duncan Smith is a zealot who actually tries to justify further punitive cuts to disabled people’s provision by claiming that working is “good” for people and is the only “route out of poverty.”

Presumably he believes work can cure people of the serious afflictions that they erroneously thought exempted them from full-time employment. 

He stated: “There is one area on which I believe we haven’t focused enough – how work is good for your health. Work can help keep people healthy as well as help promote recovery if someone falls ill. So, it is right that we look at how the system supports people who are sick and helps them into work.”

Duncan Smith undoubtedly “just knows” that his absurd claim is “right.” He’s never really grown out of his “magical thinking” stage, or transcended his dereistic tendencies. His department had to manufacture “evidence” recently in a ridiculous attempt to support Iain Duncan Smith’s imaginative, paternalist claim that punitive sanctions are somehow “beneficial” to claimants, by using fake characters to supply fake testimonials, but this was rumbled and exposed by a well-placed Freedom of Information request from Welfare Weekly.

Recent research indicates that not all work serves to “keep people healthy” nor does it ever “promote recovery.” This assumption that work can promote recovery in the case of people with severe illness and disability – which is why people claim ESA – is particularly bizarre. We have yet to hear of a single case involving a job miracle entailing people’s limbs growing back, vision being restored, or a wonder cure for heart failure, cerebral palsy, multiple sclerosis and lupus, for example.

The government’s Fit for Work scheme is founded on exactly the same misinformative nonsense. It supports profit-making for wealthy employers, at the expense of the health and wellbeing of employees that have been signed off work because of medically and professionally recognised illness that acts as a real barrier to work.

Furthermore, there is no proof that work in itself is beneficial. Indeed much research evidence strongly suggests otherwise.

And where have we heard these ideas from Iain Duncan Smith before?

Arbeit macht frei.

If work really paid then surely there would be no need to “nudge” people by using sanctions, regardless of whether or not they are employed. “Making work pay” is all about reducing support for those who the government deems “undeserving,” to “discourage welfare dependency” by making any support as horrible as the workhouse – founded on the principle of “less eligibility”, where conditions for those in need of support were punitive and kept people in a state of desperation so that even the lowest paid work in the worst of conditions would seem appealing.

The public/private divide

For a government that claims a minarchist philosophy, remarkably it has engineered an unprecedented blurring of public/private boundaries and a persistent violation of traditionally private experiences, including thoughts, beliefs, preferences, autonomy and attitudes via legislations and of course a heavy-handed fiscal conflation of public interests with private ones.

This also caught my attention from Matthew Hancock’s speech transcript:

“My case is that we need continuous improvement in public services. And for that we must reform the relationship between citizen and state. [My bolding]

“The case for reform is strong. Because people have high and rising expectations about what our public services should deliver. Because budgets are tight, and we have to make significant savings for our country to live within her means.”

Basically, the “paternalistic libertarian” message here is that we will have to expect less and less from the state, as the balance between rights and responsibilities is heavily weighted towards the latter, hence requiring the “reform” of the relationship between citizen and state.

However, surely it is active, democratic participation in processes of deliberation and decision-making that ensures that individuals are citizens, not subjects.

Social democracy evolved to include the idea of access to social goods and improving living standards as a means of widening and legitimizing the scope of political representation.

Political policies are defined as (1) The basic principles by which a government is guided. (2) The declared objectives that a government  seeks to achieve and preserve in the interest of national community. As applied to a law, ordinance, or Rule of Law, it’s the general purpose or tendency considered as directed to the welfare or prosperity of the state or community.

Once upon a time, policy was a response from government aimed at meeting public needs. It was part of an intimate democratic dialogue between the state and citizens. Traditional methods of participating in government decision-making include:

  • political parties or individual politicians
  • lobbying decision makers in government
  • community groups
  • voluntary organisations
  • public opinion
  • public consultations
  • the media

Nowadays, policies have been unanchored from any democratic dialogue regarding public needs and are more about monologues aimed at shaping those needs to suit the government. 

Nudge does not entail citizen involvement in either its origin or design. The state intrusions are at such an existential level, of an increasingly authoritarian nature, and are of course reserved for the poorest, who are deemed “irrational” and incapable of making “the right decisions.”

Yet those “faulty decisions” are deemed so from the perspective of the Behavioural Insights Team, (the “Nudge Unit”) who are not social psychologists: they are predominantly concerned with behavioural economics, decision-making and how governments influence people – “economologists”, changing people’s behaviours, enforcing compliance to fulfil political aims. That turns democracy completely on its head.

The Nudge Unit gurus claim that we need help to “correct our cognitive biases”, but those who make policies have their own whopping biases, too.

Nudge is the new fudging

Nudge is a prop for New Right neoliberal ideology that is aimed at dismantling a rights-based society and replacing it with an insidiously nudged, manipulated, compliant, and entirely “responsible”, “self-reliant” population of divided, isolated state-determined individuals who expect nothing from their elected government.

The Conservatives are obsessive about strict social taxonomies and economic enclosures. The Nudge Unit was set up by David Cameron in 2010 to try to “improve” public services and save money. The asymmetrical, class-contingent application of paternalistic libertarian “insights” establishes a hierarchy of decision-making “competence” and autonomy, which unsurprisingly corresponds with the hierarchy of wealth distribution.

So Nudge inevitably will deepen and perpetuate existing inequality and prejudice, adding a dimension of patronising psycho-moral suprematism to add further insult to politically inflicted injury. Nudge is a fashionable fad that is overhyped, trivial, unreliable; a smokescreen, a prop for neoliberalism and monstrously unfair, bad policy-making.

As someone who (despite the central dismal and patronising assumptions about the irrationality of others that king nudgers have as a central cognitive bias and the traditional prejudices that Tory ideology narrates,) manages to make my own decisions relatively without bias, intelligently, rationally, critically, carefully and coherently, and that, along with my professional and academic background, I can and will conclude that no matter how you dress it up, nudge is a pretentious, cringeworthy pseudo-intellectual dead-end.

 A Nudge for the Conservatives from history

The more things change for the Tories, the more they tend to stay the same.

In the 1870s, England had a recession and the Conservatives launched a Crusade of cuts to welfare expenditure to diminish “dependency” on poor law outdoor relief – non-institutional benefits called “out-relief” because it was paid to the poor in their own homes from taxation, rather than their having to go into the punitive “deterrent” workhouses.

The Crusade included cutting medical payments to lone mothers, widows, the elderly, chronically sick and disabled people and those with mental illness. The 1834 Poor Law amendment was shaped by people such as Jeremy Bentham, who argued for a disciplinary, punitive approach to social problems and particularly poverty, whilst Thomas Malthus focused attention on overpopulation, and moralising about the growth of illegitimacy. He placed emphasis on moral restraint rather than poor relief as the best means of easing the poverty of the lower classes. 

David Ricardo argued that there was a problem with poor relief provision “interfering” with an iron law of wages. Ricardo claimed that aid given to poor workers under the old Poor Law to supplement their wages had the effect of undermining the wages of other workers, so that the Roundsman System and Speenhamland system led employers to reduce wages, and needed reform to help workers who were not getting such aid and rate-payers whose poor-rates were going to subsidise low-wage employers. Yet we found, despite Ricardo’s pet theory, that the poor law deterrent element served to push wages down further.

The effect of poor relief, in the absurd view of the reformers, was to undermine the position of the “independent labourer.” They also wanted to “make work pay.” And end the “something for nothing” culture. But much subsequent evidence shows that reducing support for people out of work actually drives wages and working conditions down.

Neither the punitive poor law amendment act of 1834 or the Crusade “helped” people into work or addressed the lack of available paid work – that’s unemployment, not the made-up and intentionally stigmatizing word “worklessness”.

And its utter failure as a credible account of poverty – the-blame-the-individual narrative and the notion that relief discourages “self-reliance” – fuelled the national insurance act of 1911 and the development of the welfare state along with the other civilising and civilised benefits of the post-war settlement. 

The Conservatives inadvertently taught us as a society precisely why we need a welfare state.

We learned that it isn’t possible to be “thrifty” or help ourselves if we haven’t got the means for meeting basic survival needs. Nor is it possible to be nudged out of poverty when the means of doing so are not actually available. No amount of moralising and pseudo-psychologising about poor people actually works to address poverty, and structural socioeconomic inequalities.

The government’s undeclared preoccupation with behavioural change through personal responsibility is simply a revamped version of Samuel Smiles’s bible of Victorian and over-moralising, a hobby-horse: “thrift and self-help” – but only for the poor, of course. Smiles and other powerful, wealthy and privileged Conservative thinkers, such as Herbert Spencer, claimed that poverty was caused largely by the irresponsible habits of the poor during that era. But we learned historically that socioeconomic circumstances caused by political decision-making creates poverty.

Conservative rhetoric is designed to have us believe there would be no poor people if the welfare state didn’t somehow “create” them. If the Tories must insist on peddling the myth of meritocracy, then surely they must also concede that whilst such a system has some beneficiaries, it also creates situations of insolvency and poverty for others.

In other words, the same system that allows some people to become very wealthy is the same system that condemns others to poverty.

This wide recognition that the raw “market forces” of the old liberal laissez-faire (and the current starker neoliberalism) causes casualties is why the welfare state came into being, after all – because when we allow such competitive economic dogmas to manifest, there are invariably winners and losers.

That is the nature of “competitive individualism,” and along with inequality, it’s an implicit, undeniable and fundamental part of the meritocracy myth and neoliberal script. And that’s before we consider the fact that whenever there is a Conservative government, there is no such thing as a “free market”: in reality, all markets are rigged for elites.

Public policy is not an ideological tool for a so-called democratic government to simply get its own way. Democracy means that the voices of citizens, especially members of protected social groups, need to be included in political decision-making, rather than so frankly excluded.

We elect governments to meet public needs, not to “change behaviours” of citizens to suit government needs and prop up policy “outcomes” that are driven entirely by traditional Tory prejudice and ideology.

And by the way, we call any political notion that citizens should be totally subject to an absolute state authority “totalitarianism,” not “nudge.”

demcracy
Courtesy of Robert Livingstone

Update: The government have since announced the introduction of a number of “policy initiatives” aimed at reducing the number of people claiming Employment and Support Allowance (ESA). These initiatives are currently still at a research and trialing stage. Health Management, a subsidiary of MAXIMUS are to deliver the fit for work programme, which was set up based on recommendations from the Health at Work – an independent review of sickness absence report by Dame Carol Black and David Frost. The review was aimed at “reducing the cost of sickness to employers, ‘taxpayers’ and the economy.”

Fit for Work occupational health professional will have access to people’s diagnoses from their fit notes, the fit note end date and any further information that the GP considers relevant to their absence from work or current treatment (at the discretion of the GP). The primary referral route for an assessment for the Maximus programme will be via the GP.

The government is cutting funding for contracted-out employment support by 80%, following the Spending Review. The Department for Work and Pensions has indicated that total spending on employment will be reduced, including not renewing Mandatory Work Activity and Community Work Placements, the new Work and Health Programme will have funding of around £130 million a year – around 20% of the level of funding for the unsuccessful Work Programme and Work Choice, which it will replace.

Iain Duncan Smith says: “This Spending Review will see the start of genuine integration between the health and work sectors, with a renewed focus on supporting people with health conditions and disabilities return to and remain in work. We will increase spending in this area, expanding Access to Work and Fit for Work, and investing in the Health and Work Innovation Fund and the new Work and Health Programme.” 

Meeting the Government’s goal of halving the employment gap between disabled and non-disabled workers – moving around one million more disabled people into work – will be no easy task. Not least because despite Iain Duncan Smith’s ideological commitments, and aims to “reduce welfare dependency,” most disabled people who don’t work (and claim ESA) can’t do so because of genuine and insurmountable barriers such as incapacitating and devastating, life-changing illness. No amount of targeting those people with the Conservative doublespeak variant of “help” and nasty “incentivising” via welfare sanctions and benefit cuts will remedy that.