The author is a physician with a practice in the North-West.
It is vital that those suffering from disabling health conditions are well supported by the welfare system. However it is my belief that in some cases well-meaning welfare provisions can end up having severe unintended consequences.
As a physician I have previously worked in areas with a broad range of demographics and have seen the various stimuli that lead to and from ill-health. A fact that many on the inside, but few on the outside know is that a common driver to ill health is the welfare state. In short, it appears that being sick has become a way of life and a career choice for a worryingly high percentage of the population.
Disability benefits have the potential to inadvertently encourage a state of dependency, and incentivise an individual to remain sick. Two patients can have identical pathology – for example identical objective deficits from multiple sclerosis – but with striking differences in illness behaviour. It its current form the welfare system is prone to misuse. For those in legitimate need, disability benefits can enable them and restore livelihood. For others however disability benefits can incentivise work avoidance.
But how extensive is the problem? How can a doctor tell if symptoms are being exaggerated? We are advised in medicine not to use the word malingering, but rather ‘subconscious amplification of symptoms’. It can be very difficult to know how much is subconscious and how much is amplified. One informal survey of colleagues from around the UK placed the figure at between 10% and 90%. Interestingly, if the question is restricted to doctors working in areas of high unemployment then a much higher figure is reached. This is of course not surprising as the alternative prospects for individuals are far more limited.
As an illustration, an intravenous drug user I once saw had lost use of his arm because of a drug-related incident. When I told him that he would not recover the function of his arm I was expecting great disappointment, but instead got the surprising reaction, “great, does this mean I will get benefits?”
When the disability reassessments were introduced a couple of years ago many colleagues saw a sudden and unexpected worsening in patients symptoms. Patients who previously had well-controlled epilepsy reported more seizures or that their pain had worsened. As well as costing the system, it also makes the doctor’s role difficult in trying to judge what is true illness and what is amplified, leading to more investigations, more hospital appointments, more drugs.
Such over-dependency can have a distortionary effect on the wider economy. Individuals on chronic welfare increasingly move from the affluent South-East to the North because there is a greater availability of social housing, and living costs are lower. In contrast, talent migrates from the North to the South-East because of better prospects. This then compounds the situation. It is an interesting observation that the area of the country with by far the lowest per capita spend on infrastructure, the North-East of England, has the highest welfare spend. In effect, successive government policy has attempted to enforce a deal on the population of providing the South with the investment and tools to generate the returns and then transfer some of this to the north in welfare payments. In crude terms, investment follows place (South), welfare follows people (North).
More importantly, over-dependency is not good for the individual. They become locked into a way of life with reduced well-being, and the attendant inactivity for many patients leads to further illness and obesity. Most significantly, I have observed that not working can result in a loss of sense of purpose, of personal value of being in a team.
Not only does the current welfare system incentivise false claims, it can also overlook legitimate ones. Many doctors have patients who they think deserve benefits yet don't get them. Or the receipt of benefits is unacceptably delayed. Thus there is a mismatch between patients on long-term benefits driven by the financial incentives of the system and becoming less employable, but other patients who we desperately want to get better and faster support. In essence, the disabled are suffering from the actions of others.
Why does the assessment system not weed out such cases? Firstly, I believe that welfare assessment should focus on what can be done, not what can’t be done. The ability to accurately assess disability and levels of dysfunction can be very difficult. In some cases even skilled physicians with decades of experience can get it wrong. The inaccuracy that results is compounded further by the current assessment procedure, which pressures physicians to not be entirely open. This is because the patient can review the report before it is sent off for approval. A doctor’s performance is determined by their patient throughput and number of complaints received. Thus by conceding to a patient’s expectations a doctor can avoid a potentially hostile confrontation and complaints on their record. Indeed the degree to which patients can pursue doctors who do not give them what they want is so great now that once one has been bitten, the easy option is much more likely to be followed.
In this regard I believe the views of the ex-head of the NHS litigation authority were shockingly naive when he stated that if we eliminated errors there would be no complaints. In reality the relationship between errors and complaints is surprisingly shallow.
Some doctors will provide diagnostic labels which provide a potential ticket to benefits, which if examined closely are part of the normal spectrum. A common example I see is patients being diagnosed with joint hypermobility syndrome with associated pain. When does a flexible patient become hypermobile, and why does this lead to some developing chronic pain and on benefits? Or take depression, which affects 1/3 of the adult population at some stage. There is a big difference though between someone needing sectioning and ECT, and someone needing citalopram and a bit of cognitive therapy.
1. Doctors reports should be anonymised and made confidential. The current forms are better than the previous ones, but need support from non-assessment service doctors and this will work best if those doctors can be open and frank.
2. Illness/disability benefits assessments should be designed to identify activities which an individual can do, not what they can't do. The Government must encourage the full range of mental, physical and social activities. For example, if an individual took extra welfare support for one domain, they would be required to utilise other domains. e.g., if a patient were wheelchair-bound but had full mental faculty then financial support would be provided to assist with mobility only if they were active in terms of work (even if only voluntary work) that required their mental faculties or social engagement. Conversely an individual with mental health problems and unable to function in a stressful work environment could be supported in using their physical abilities, for example with manual work or even befriending lonely elderly individuals.
3. For conditions which can be ameliorated by the action of the individual, greater emphasis should be placed on determining the right balance between disability payments and programs that emphasise greater personal responsibility for recuperation.