A Rebuttal to the Physician at the Centre for Policy Studies.

The Centre for Policy Studies (Motto “To question the unquestioned, to think the unthinkable, to blaze new trails”, or possibly “To generate hate-clicks”) released this lovely article today;

Illness as a Career Choice, by Administrator CPS

(Don’t worry, I’m going to replicate basically the whole thing below if you don’t want to give them clicks.)

The writer was “A physician with a practice in the North-West.” and honestly, the simple fact that nobody is putting their name to this suggests that they know that it’s basically hate speech, and that it’s doing nothing but add to the amount of discrimination and suspicion that disabled people are put under.

So, let’s begin;

It is vital that those suffering from disabling health conditions are well supported by the welfare system.

Excellent. We can stop there and go home for tea. No more input required, you’ve got it right.

However it is my belief that in some cases well-meaning welfare provisions can end up having severe unintended consequences.

Oh, goody. Please, share your wisdom with us. Anyone who phrases it like that is never going to go on to say anything like “Assessments and conditions intended to make the process fairer are actually hurting disabled people and often removing their safety nets from them.”

Onwards;

As a physician I have previously worked in areas with a broad range of demographics [Translation – Somewhere with nice middle-class people in it too, not just stupid tricksy povvos] and have seen the various stimuli that lead to and from ill-health. A fact that many [how many?] on the inside [who?], but few on the outside know is that a common driver to ill health is the welfare state [citation needed]. In short, it appears that being sick has become a way of life and a career choice for a worryingly high percentage [how high?] of the population. [citation needed]

So paragraph one seems to say “Us doctors think that people decide to be ill in order to get benefits”. If that’s really the attitude of most of the medical profession, then we’re going to need a radical overhaul of the whole system. Doctors are meant to treat the sick, not prop up the state’s scapegoating rhetoric.

Disability benefits have the potential to inadvertently encourage a state of dependency, and incentivise an individual to remain sick. [Because people can absolutely will themselves to not be ill! If I just concentrated a bit harder, my hips wouldn’t fall out of their sockets every few steps.] Two patients can have identical pathology – for example identical objective deficits from multiple sclerosis – but with striking differences in illness behaviour.

Surely, then, they’ve got a different pathology? Illness isn’t just “Objective defecits”, it’s a complicated interaction involving all of the body’s systems. For example – Someone with a lower Beighton score might have more pain that someone with a higher one, but the person with more pain may be more mobile. It’s complicated.

It its current form the welfare system is prone to misuse.

Figures released earlier this week by the DWP itself (July 2014), reminding us that only 0.7% of benefits are overpaid due to fraud, and that only 2% of benefits are overpaid at all. Just to put this concerned physician’s feelings into perspective.

For those in legitimate need, disability benefits can enable them and restore livelihood. For others however disability benefits can incentivise work avoidance.

Not certain how someone can be a doctor without knowing this, but some disabled people will never get better. And another friendly reminder that PIP (Personal Independence Payment) is an in-work benefit, paid to make up the difference between how much it costs to live as an abled person and as a disabled person. It’s about twenty to a hundred and thirty eight quid a week, and to get that highest rate you have to be extremely crippled – As in, unable to walk more than 20 yards, probably intontinent, incapable of washing self. ESA (Employment Support Allowance) tops out at about a hundred and eight quid a week, which isn’t exactly footballer money either. So yeah, if you’re willing to commit to living on less than £1,000 a month, before tax, to attend the jobcentre constantly for “interviews” with an “advisor” and to go on interminable training courses, and then to have to reapply for ESA again every year, which will leave you with a fourteen-week gap with no money in which you’re not allowed to work, and thus basically three months of living on £400-ish… All the while “faking” a disability, then be my guest.

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.

The colossal margin for error and the increase when looking at areas of high unemployment actually says a couple of very different things to me; a) That an “informal survey of colleagues” means “I phoned some of my mates and they agreed with me” and b) That this has a lot to do with the subconcious prejudices of doctors against the poor and working-class.

It’s a vicious cycle – Doctors “know” that the poor are just out for all they can get, money-for-nothing, and probably drug-seeking bad-back-fakers, and thus doctors observing poor patients in pain will assume that they’re malingering. And no, dressing it up as “Subconcious amplification of symptoms” is just a code word. That’s like saying “I didn’t say you were hysterical, I said that you were suffering from delusional and disproportionate anxiety”. Wrapping things in prettier words whilst maintaining the underlying bias is not progress.

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?”

That actually sounds like the kind of gallows humour I’d use in that sort of situation too. It’s the writ-large version of “Migraines are hell, but at least I never have to buy eyeshadow”.

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.

Translation: “Sick people suddenly placed under a lot of stress had massive flare-ups of their condition.” Anyone who is shocked by this needs to go back to first year.

Such over-dependency can have a distortionary effect on the wider economy. Individuals on chronic welfare [That’s a new way of making long-term claimants sound suspicious! And it chucks in a nicely ableist comparison too! Well done!] increasingly move from the affluent South-East to the North because there is a greater availability of social housing, and living costs are lower.

Translation: “Poor people in going-where-it’s-cheaper-to-live shocker”. And let’s not forget that London is exporting its council tenants.

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).

That is probably the worst attempt at understanding cause-and-effect that I’ve ever seen. If you put it as “Due to the Government’s failure to invest in the North East, a large percentage of its most able inhabitants have moved south, leaving disproportionate numbers of poor and less-educated people behind. Sometimes people are poor and less-educated due to disabilities which make it difficult to work or study.” it places the blame more solidly at the correct door. Also, the further use of the North East as being a land full of mythic benefit-cheats and lost-causes is really, really classy. Nothing like using a cheap and unfair stereotype to back up your bigoted views.

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.

Another paragraph of “People are only ill because they’re not trying hard enough!” followed by;

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.

Which seems to be trying to place the blame for the DWP and Atos’ slow processing of claims onto the 0.7% of fraudulent claimants. But since the writer won’t admit that it’s only 0.7% of claimants, it’s basically an attempt to divide the disabled, and to make them look at each other and see enemies and fakers. And I’m fairly certain that the “patients who [the doctors] think deserve benefits” is basically code for “Nice middle-class people”, especially since I can only assume that this is from the same survey as the writer’s earlier “informal survey” of their friends.

Why does the assessment system not weed out such cases? [Another reminder of that MASSIVE 0.7% fraud rate, by the way.] 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. [And yet the DWP believes that an hour with their nurse is more valuable than several years with your own consultant] 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.

Shock! Horror! Doctors might have to actually consult with patients when talking about them to a third party! Patients might have more input and insight on their daily lives than a doctor has, despite the doctor seeing them probably less than once a month and the patient only being with the patient every day! If you’re a doctor, and you’re getting endless complaints from patients who think that you’ve misjudged them and who are demanding a higher standard of care… Maybe you’re just not a very good doctor. Maybe you need to look at them with a little bit more compassion, and actually listen to their problems and trust that most people are really quite understated when talking about their symptoms. Maybe you need to question what you think the role of a doctor is, if you don’t believe that they should be accountable to their patients.

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. [citation needed]

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.

Because apparently this still needs clearing up;

Being A Bit Bendy is the state of having very supple joints which allow you to attain postures considered unusual by most people. It is not painful.

Joint Hypermobility Syndrome is a condition which involves defects in the production of collagen and the sometimes the formation of bones, which results in chronic pain, complications in multiple organs (Skin, gut, heart and eyes being the most common) adrenal problems, digestive problems, anxiety and depression, and a whole host of other problems. The DWP even has guidance on it, so possibly the writer just needs to learn to use Google. There are a huge number of ways that hypermobility and “being a bit bendy” are really, really difficult and I would have thought that was the sort of thing that someone had to know to be a GP. Kind of like telling the difference between being a bit short and being an achondroplasic Dwarf.

Anyway, not far to go now;

When does a flexible patient become hypermobile, and why does this lead to some developing chronic pain and on benefits?

The first half of that question is actually really interesting, but is still better phrased as “Why do some hypermobile patients remain asymptomatic, when some have serious losses of function and chronic pain?” since we’ve already determined that “flexible” and “hypermobile” aren’t really related. There’s huge amounts of research being done by various EDS foundations to try to work out how to keep us asymptomatic, because it gives us a better quality of life. The “On benefits” part of the question is probably best answered with a very simple “If someone is really badly hurt, and can’t work, then the nice Government gives them money so that they don’t have to beg on the streets. If they’re not hurt, the government won’t give them money, and they have to go to work. The government takes a tiny little bit of money from all of the non-hurt people who are at work, and gives it to the people who are hurt.” but that’s the kind of explanation that I would expect to give to a toddler, not a physician.

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.

There is a big difference – And that’s why someone who takes a little bit of Citalopram for a few months isn’t going to get disability benefits. Or if they are, it’s going to be at a very low rate, and it’s basically going to make getting to-and-from work easier for them, so that they get to keep their job. More likely though, they’ll at most be signed off with statutory sick pay for a few months, then go back to work as soon as they can. Because not everyone who applies for benefits gets them – The type of mental illness that gets you disability benefits of any kind is the type that’s lifelong and absoutely wrecks your ability to function.

That’s the end of the main article, by the way. The writer seems to think that this is some kind of trump card. They then go on to some “Proposals”;

 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.

Counterproposal – Doctors should discuss with their patients what their expectations are and encourage them to be honest about their symptoms. Doctors should believe their patients, because they’re doctors, not detectives.

 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. [Orwellian, much?] 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.

Counterproposal – We do not have to prove ourselves useful just to survive. The writer’s attempt at making a mind/body dichotomy is ridiculous. This whole section is even worse when we remember that they’re talking about people who are currently just considered to be too ill to work. Physical illnesses come with pain that makes it difficult to concentrate. Physical illnesses often result in simple tasks like getting dressed or eating a meal taking much longer than normal, thus making it impractical to work, since the employer could not rely on attendance. Mental illnesses cause fatigue and lack of energy and inability to socialise – It’d be downright cruel to the elderly to inflict depressed-me on them, for starters. Having obligations to the Government, which you have to complete to get paid your benefits, is incredibly stressful even if it is just “Manual labour” and I can’t imagine that being good for the mental health either.

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.

Counterproposal – I do not want this writer, or anyone who has as little contact with me as an ATOS nurse or a DWP official, deciding for me what the “Right balance” is between giving me money to let me continue living, and taking money away from me as a punishment for not getting well fast enough. Funnily enough, having money allows claimants to do things like get to their hospital appointments, go to the gym for physiotherapy, buy healthy food, keep going out to maintain a sense of self-worth, and things like that. Basically, all the things which give them a higher chance of one day rejoining the workforce. And they’re more likely to do those things if they aren’t being forced to do them on the DWP’s timescale.

Honestly, I hope that the original article was written as a deliberate parody.

Physician, how do you justify your position, considering that it’s so based in a mixture of ableism, victim-blaming, class stereotypes and having swallowed the Tories’ spin hook line and sinker?

Yours faithfully,

-Percy

(A proud Geordie with a bad back, hypermobility syndrome and depression. So probably just worthless scrounging scum, really.)

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