Illness as ‘Deviance’, Work as Glittering Salvation and the ‘Psyching-up’ of the Medical Model: Strategies for Getting The Sick ‘Back To Work’.

by Gill Thorburn

The one thing I am absolutely unreservedly and implacably opposed to in all of this is a real world test.” – Chris Grayling, Minister of State, Department for Work and Pensions, 2011.

An ongoing British government mission of ‘inclusivity’ which has sought to draw into paid employment those previously depicted as ‘excluded’ by conditions of personal circumstance, such as lone mothers, or through lack of ‘skills’ such as NEETS, or to some extent disabled and older claimants, has recently been expanded much further, venturing into territory previously delimited by, and existing under the protection of, certain ‘norms’ – that is the widespread area of sickness and disability. Characteristic of government rhetoric towards an end of ‘including’ the sick and disabled within the work-not-welfare paradigm is the adoption of an ‘abandonment’ discourse when referring to those on long-term health-related benefits (Grayling, quoted in BBC, 2011) – work being posed as their ‘salvation’.

Chris Grayling

It is necessary to concede, first of all, that the right kind of work, with the appropriate support, can contribute to the well-being of those disadvantaged by illness or disability, and afford them at least a share in the positive benefits that accrue to the ‘able-bodied’ from engaging with paid employment. This is particularly in contrast to the poverty level that welfare benefits are set at, it must be added. It is a highly contingent situation, however, and subject to factors beyond their control, such as the concessions employers are willing to make to the irregularities that the physically or mentally impaired worker brings into the workplace, those for whom adaptations or adjustments must be made. Modern employers in a competitive business environment are increasingly disinclined to adapt working conditions to the worker, seeing it as the latter’s responsibility to ‘fit in’ to an established work structure, evidenced in their reported attitude towards young UK adults, perceived as “ill-equipped and poorly prepared to face the working world due to their reluctance to take on menial jobs, especially those involving dirty or monotonous tasks and over-long or anti-social hours”  (Learning and Skills Council, 2006). This is also a tacit admission by employers of the adverse conditions that prevail in the modern workplace.

This wave of inclusivity, then, has now broached an area that, until recent times, had embedded within it certain norms, which could be said to be part of a prevailing ‘humane’ discourse around sickness and disability in our society. For instance the revulsion that is held towards the German Third Reich’s euthanistic program, with its accompanying defamation of the sick and disabled, is illustrative of the sense in which that sector of the populace is acknowledged as vulnerable and deserving of support. Intrinsic to this perception is the notion that the ‘forced independence’ on this group of responsibility for their own wellbeing, through the removal of the social support it relies upon on, would be regarded as a cruelty. Further there is a sense of “there but for the grace of god…” which determines the moral values inherent in these shared norms, and a recognition that infirmity is an inevitable consequence of the aging process which touches all. It is in this sense that until recently the place of work in any ‘illness’ discourse has been marginal and tempered by notions of relevant limitations as to its positive effects.

To contravene these established compassionate norms, then, requires a compelling and strongly persuasive argument, one which is capable of overturning common sense conceptions; that work can cause further difficulties for the sick and disabled, or indeed that work has played a significant part in contributing to illness in the first place. Despite these moral inhibitions, this has now been achieved within the context of welfare policy changes around sickness and disability, and it is an argument which has emerged from a very deliberate theoretical and ideological process. This process has led to the embedding into social policy of the simple, abstract idea that “work is always good for you” (no matter what the circumstances), and has provided the ideological foundation for the implementation of the ‘medicalised bureaucracy’ of the Work Capability Assessment (WCA), administered by the government’s private sub-contractor, Atos Healthcare. The WCA is constructed as a filtering instrument by which those claiming incapacity for work can be ‘streamed’ into categories of; the “work ready”, those “having some barriers to work” and those who are “unlikely to ever be capable of working”. Increasing evidence is accumulating to the effect that this instrument is failing to be fit for purpose (Harrington, 2010; Royston, 2010; Black Triangle, 2011; After Atos; and countless other blogs, campaigns and personal accounts distributed both across the internet, and out on the street1) – unless of course that purpose is to remove welfare from the sick.

If social policies, and the associated bureaucratic procedures through which they are implemented, can be regarded as the visible front-end of government then there is also a corresponding hidden region, where the theories and ideas that lend these policies legitimacy are generated. These theoretical underpinnings are far less likely to be exposed to wider public scrutiny; rather it is accepted on trust that they have substance and arise from authoritative evidence. One set of ideas that has strongly influenced the course of recent reforms has been the deliberate attempt to formulate a ‘New Model Of Illness’ (Waddell and Aylward, 2010), one which the creators assert to be a more appropriate one than the ‘bio-medical’ model, which they claim is an outdated perspective on illness and its relationship to incapacity.

This new approach, a ‘Biopsychosocial’ (BPS) model, originated from the work of George Engel, a trained physician who ‘converted’ from physical to psychosomatic medicine, becoming a leader in the discipline, despite his initial scepticism towards that field. Though there is no definitive text on the theory it is a simple enough concept which reveals its approach in its title. Briefly put, it is a theory that seeks to broaden the perspective on illness, by taking into account not only the biological, but also psychological and social factors which may have an influence on sickness, and consequently on the course that healing takes. The acknowledged value of this approach, when used for the benefit of the patient, is that it allows for the identification of non-biological influences which may interfere with an individual’s capacity to heal. Further indicators of the model’s intended use and objectives can be found in recent re-evaluations taken 25 and 30 years on. With respect to the latter, a Science Daily article (2008) describes it as having posed a ‘challenge’ to the conventional molecular biology perspective, but that it has proven effects through ‘psychotherapeutic strategies’ which facilitate coping and improve quality of life.

Their definition portrays a model which is capable of being tailored to the individual, the assumption being that, once identified, non-biological factors inhibiting healing will be addressed through the accessing of diverse kinds of support that, it is assumed, will be available to the patient. The article also puts significant emphasis on “stressful life events and repeated or chronic environmental challenge in modulating individual vulnerability to illness“, an acknowledgment that these have real effects on a person’s illness, conferring a measure of legitimacy on ‘medically unexplained symptoms’, which it will be seen are afforded a quite different focus within the research which underpins current government policy. The most appropriate use of BPS, it can then be concluded from this, is within healthcare, and amidst a context of widely available services. This quite specific application is confirmed by an earlier re-appraisal, (Borrell-Carrió, 2004) which testifies to its value in clinical assessments, underscoring this context by a defence of its “contribution to the scientific clinical method”. It additionally notes that there is an aspect of BPS which encourages a ‘participatory clinician-patient relationship’, suggestive of an equalising of the power distribution between the two roles “which may not be universally accepted” (presumably by the medical profession). Overall this review, too, emphasises that the value of BPS is as a method which is used according to “the needs of each patient”.

A very different application of this method is found among the material underpinning current government welfare policy that, nevertheless, attempts to substantiate itself through reference to the BPS model. Criticisms exist which argue that theories are open to ‘misreading’ and therefore misapplication, their principles appropriated towards ends which oppose their established purpose. Harvey and Reed (1996), for example, contend that Lewis’ (1969) ‘culture of poverty’ thesis, so widely utilised towards an end of ‘blaming the victim’, was not intended to be a denigration of the poor, but rather proof of their “resilience and resourcefulness … and the cultural defenses they erect against poverty’s everyday uncertainty”.  Similar charges could be laid at the door of those seeking to erect this new model of illness for a purpose that deviates from the strictly clinical ones outlined above. It is the contention of this article that a prime purpose behind recent use of the BPS is to create an artificial distinction between deserving and undeserving sick, through the social construction of a new category of patient/claimant – the illness deviant – in order to facilitate the movement of a high percentage of those claiming illness related benefits off welfare, via the aforementioned WCA.

Due to the shared characteristics of the personnel involved in this project, the public and private sector connections they share (Rutherford, 2007), and the manner in which they have ‘pushed’ the ideas contained within their literature, I propose to refer to them as ‘the BPS lobby’. A leading figure of this movement, Professor Mansel Aylward, formerly Chief Medical Officer with the DWP, is director of the Psychosocial and Disability Centre at Cardiff University, the establishment of which, in 2004, was funded by the global insurance firm, Unum. The body of Aylward’s research and theoretical enquiry, ostensibly via the BPS model, has a peculiarly singular slant considering the diverse nature of that perspective; that is a relentless emphasis on an individual’s ‘beliefs’ and ‘attitudes’ towards their illness (Barnes et al, 2008). In this sense it could more aptly be termed the ‘Psycho’ model of illness, with contributors drawn almost exclusively from within that discipline. Publications exemplifying this bias are too numerous to mention, dominating as it does the lobby’s discourse, but include Aylward’s  co-authored book ‘The Power of Belief’ dedicated to addressing the purported “epidemic of common health problems” that is said to be ‘beleaguering’ British society. A feature of the lobby’s literature in general is the framing of this ‘problem’ in ‘mysterious’ terms, as a ‘paradox’, something unexplainable against a context of the alleged ‘improvement’ in general health of the nation. This assumption it will later be shown, based as it is on a generalisation of data, obscures the uneven distribution of these health benefits across a society stratified by occupation.

A double standard is observable within the BPS lobby’s argument against the legitimacy of ‘symptom-defined illnesses'(such as IBS, stress and back conditions). The medical establishment is asserted to have allowed the growth of ‘syndromes’, which they construct as having less validity than ‘diseases’, counterpoised as having a solid pathological basis. It is strongly ironic, then, that they do not hold psychology to the same criticism, since its epistemology is practically founded on the creation of labels around sets of observed behaviours. Aylward and LoCascio treat us to a round-up of some of the terms that have proliferated in psychology around ‘medically unexplained symptoms’: “hypochondriasis”, “hysteria”, “functional overlay”, “somatisation”, “malingering”, “illness behaviour” etc” (Aylward and LoCascio, 1995,p.19) that they state has been to ‘confusing’ effect. Though some might consider this inconsistency to be evidence of a flaw in that general theory, the authors’ motive in recounting this seems to be more in order to establish that there is something there to ‘psychologise’.

Expectation might be that a balance would be attempted between this focus on the psychology of the individual and that most ‘social’ of all activities – work. This aspect of ‘the social’, though, is almost invisible in the lobby’s publications; work is relegated, or more accurately, elevated, to a distant idea which can be summarised in the simple statement: ‘Work is always good for you’. No further justification for this astonishingly sweeping generalisation is offered than a DWP commissioned ‘independent’ literature review co-authored by one of Aylward’s colleagues at Cardiff, Gordon Waddell (Waddell and Burton, 2006). Though the document contains ‘disclaimers’ which qualify that notion in acknowledgement that work can pose hazards to health for some people under certain circumstances, the overriding message is of the positive values inherent in work, and it seeks to make it strongest case in the linking of ill-health and unemployment, concluding that “Work is generally good for health and well-being”. A ‘pamphlet’ on ‘Work and Health’ by the same authors (Waddell and Burton, 2006b) counterpoise this idea against the constructed notion of ‘Common Health Problems’, this latter term, alongside ‘Medically Unexplained Symptoms’ assuming particular prominence in the BPS lobby’s literature.

The pamphlet, aimed at a very broad audience of “those who deal with health issues at work”, including lawyers, but excluding the worker himself, frames its subject in terms of the ‘problem’ of continuing rates of sickness absence which they assert mainly involve these ‘common health problems’ of musculoskeletal, cardio-respiratory and mental health disorders. The explicit message is that people hold ‘illogical’ beliefs about the causes of their illness, which in any case, contain characteristics experienced by the population as a whole (the majority of whom, it is to be assumed, continue to work regardless) and it seeks, as much of the lobby’s literature does, to break existing conceptual links between ill-health and work. This notion is given full sway within Waddell and Aylward’s ‘Models of Sickness and Disability’ (2010). It is a minimising of ill-health which constructs the majority of the sick and disabled community as ‘deficient’ in some way, through having an ‘abnormal’ perception of their health – an ideological construct which pervades the broad literature of this lobby – the ‘paradox’ being “that so many end up with long-term disability”. Perhaps aware of the perceivable bias in their approach the authors contend that though “there is usually no good medical explanation…we must not jump to the conclusion that it’s malingering.”

This is not an inhibition that is demonstrated within a particular collaboration which brings together through contribution, but also in acknowledgements and references, many of the high profile individuals, such as Aylward and Waddell, who have been involved in directing the course of recent work-as-welfare policies for the sick and disabled (Rutherford, 2007), or have generally provided a major influence on official and public perceptions of certain illnesses. It is the ‘big book’ of ‘Malingering and Illness Deception’ (Halligan et al, 2003). This is a volume which can only be described as remorselessly zealous in the pursuit of its topic, so heavily belaboured is the message that deception is rife among humans, and the sick are no exception. It marshals every possible argument, covering a span from history to neuroscience, drawing even upon child development theories and the vague, unproven proposition, via primate studies, that ‘feigning’ sickness may be embedded into our very evolution.

The treatment is so ‘thick’, the overall impression contributing to a sense of paranoia about deception around every corner, that, were it a human, one would expect it to be wearing a tinfoil hat. But, fear not, reassurance is on hand in the form of the closing section, which focuses on the progress made in ‘deception detection’ and the news that neuroscience may be on the verge of developing scanning technology with which to indentify lying activity in the brain. This publication seems to have been welcomed by the ‘psycho’ professions, with one reviewer from that field expressing delight at the way the book “gets off to a cracking start” (Fleminger, 2004), almost as if it was a bestselling thriller, rather than the purported exposition of a serious issue for the medical profession. Somewhat unseemly for a professional to express such glee at the fact that “many of our patients may be deceiving us, and that much of this deception may be conscious“. Fleminger particularly seems to relish Wessely’s “delightful tour of the history of malingering”, concluding that though the book is not likely to be of any help in detecting deceit, readers will have been “entertained and educated“. In this sense, considering the ostensibly serious tone of the book, perhaps there is an aspect of it, with respect to certain of its target readership, which is acting as a ‘dogwhistle’, encouraging and reinforcing scepticism, doubt and cynicism of professionals towards those in their care.

The BPS model is consistently deployed in the framing by this group, across the span of their publications, of an ‘illness deviance’, its principles drawn upon to emphasise the (flawed) ‘subjectivity’ of those suffering ill-health in a way which seeks to undermine their credibility, asserting that there has been a proliferation of ‘medically unexplained symptoms’, juxtaposed against the notion that the majority of health problems are ‘common’, and therefore experienced ‘commonly’ within everyday human experience by most people. This purpose could not be further from the intent of its originator who declared that “[M]any illnesses are largely subjective – at least until we as observers discover the parameters and framework within which we can also make objective observations. Hyperparathyroidism, in many of its manifestations, was a purely subjective experience for many patients until we discovered what to look for and which instruments to use in the search”. (Engel, 1961). Engel further sounds a cautionary note for those involved in the production of new knowledge: qualifying a definition of research as “to see what everyone else has seen and think what nobody else has thought” with a caution not to fall into the trap of thinking that the ‘new’ thought is necessarily any more correct. It is something perhaps that the BPS lobby might well have borne in mind considering the serious effects their ‘theories’ are now having on the lives of the sick and disabled 1.

One initial area of illness which has been exposed to the notion of the ‘medically unexplained’ is that of conditions of the lower back, symptomatically presenting as an individual’s subjective experiencing of pain, and therefore incapacity, in that region, without, it is asserted, any detectable underlying physical pathology. A leading figure from within the BPS lobby in this topic is Gordon Waddell, whose publications, notably his ‘Back Pain Revolution’ (2004), have become key sources in the referencing of ‘medically unexplained symptoms’. Revealingly, his work is referenced over fifty times within the aforementioned ‘Malingering’ book. Of note in this regard is Waddells’ attempt to distance his work, specifically his diagnostic tool, ‘Waddells’ Signs’, which has acquired a reputation for use in discrediting litigants in industrial negligence cases (Gelman and Brazin, 2000; Personal Injury News, 2008) from any notion that it intends to prove malingering. The fact that this disclaimer is reported within the book on malingering itself lends a certain irony to the situation. Much of Waddell’s, and his colleagues’, literature centres, as discussed, around ‘medically unexplained symptoms’, and the assertion of no underlying physical pathology. Implicit within this perspective is a strangely unscientific notion that the existing state of medical knowledge/technology is the final word diagnostically, contrasting with Engel’s insight that medical science often needs to ‘catch up’ with subjective patient experience, through the development of new ‘instruments’. It is just such an occurrence which now casts doubt upon the dismissing of musculoskeletal disorders as lacking detectable pathology. Recent developments in medical technology (University of Aberdeen, 2000) have highlighted the limitations of conventional MRI in detecting the physical causes of musculoskeletal conditions, a category that takes centre stage among the BPS lobby’s ‘medically unexplained’ disorders. Under conventional, non-weight-bearing MRI “the conditions under which symptoms arise are often not reproduced” due to the patient lying down. (Group Health, 2010). New ‘weight-bearing’ i.e. upright MRI technology is proving to have a superior capacity in more accurately identifying the pathologies behind these conditions.

For all the BPS lobby’s assertion that theirs is a more explanatory model of illness their usage of BPS is very unbalanced in favour of its psychological (and therefore, individualised) roots, at the expense of the ‘social’. Yet it is in that sphere where a much more convincing argument for a cause in the rise in musculoskeletal disorders can be found, whether or not the technology yet exists to ‘detect’ them; that is in the changes that have occurred in work practices, conditions and environments, particularly for the low-waged. Within Aylward et al’s conceptual framework the social practice of work is awarded an uncritically positive value (Waddell and Burton, 2006) as opposed to the immense range of activities that constitute it in the ‘real world’ (Dean, 2010), or the diversity of experiences a worker may encounter in the contemporary unequal spread of benefits across the ‘division of labour’. Supporting a competing notion of the effects of work on wellbeing the Cardiff and Oxford Universities based ESRC Centre on Skills, Knowledge and Organisational Performance (SKOPE) has conducted substantial research into ‘bad jobs’ (Payne, 2011). A volume of their findings on working conditions experienced across a range of low paid employment was published in the U.S (Lloyd et al, 2008) as part of a project to assess this sector of the working population across selected European countries and America. A chapter on the food processing industry, which accounts for 13% of manufacturing in the UK, employing over 400,000 workers, offers a far more rational framework for the ‘unexplained’ rise in musculoskeletal disorders, than some perceived psychological defect which causes sufferers to ‘amplify’ or ‘magnify’ their symptoms. The researchers observed that in this sector “working conditions can be both extremely unpleasant (e.g. meat processing plants) as well as harmful to health and safety. Repetitive work routines that are physically demanding … can often result in injuries to the back, neck, hands and shoulders” adding that employees can be under pressure to “work long hours to make up their pay”, and that ‘gruelling’ ten hour shifts” (James and Lloyd, 2008) are common in this intensified work environment.

It is clearly evident within this and other accounts, both in the book and elsewhere (Acquiar and Herod, 2006), of the frequency with which low paid workers must submit to adverse conditions, that modern working practices and conditions are likely to have substantially contributed to the rise in so-called ‘common health problems’, with the high numbers of sufferers from these conditions completely consistent with the fact “there remains a significant number of low paid jobs (about 22% of the UK workforce) and in some instances the numbers are growing, particularly in parts of the service sector” (Lloyd et al, 2008). Consecutive chapters of the book deal with the negative implications for health of various types of low paid work, including that of hotels, retailing, hospitals, food processing and call centres. The strain of call centre work is described as being due to “the combination of high work pressure and limited autonomy”…which results in “high levels of stress…“, while the public hospital is revealed to be a place where “one in five assistant nurses and three in five cleaners are estimated to be paid below the low pay threshold”, a more convincing explanation for the rise in stress-related disorders than the BPS lobby’s ‘individualised’ concept that it arises from the ‘wrong attitude’, dismissing it as the “medicalisation of dissatisfaction”‘ (O’Donnell and Bevan, 2004). This latter term is contestable by the counter claim that there has been a ‘psychologising of work-related illness’, which process it has been the purpose of this article to highlight. The labelling game is not difficult to play, but it reveals little more than the bias of the writer, and their penchant for the ‘overarching phrase’. As journalistic investigations into low paid work, undertaken through participant observation (Ehrenreich, 2002; Toynbee, 2003; Pai, 2008) have revealed, it is more usually the case that low-paid workers are often extremely industrious, of necessity enduring harsh conditions that accompany what is regarded as low-skilled work. It is an image that is more consistent with a worker who ‘works till they drop’ than one who is deterred from working by the ‘subjective’ experience of ‘mild to moderate common health problems’ that other ‘normal’ workers are inclined to overlook.

Selective use of data can provide a misleading impression, and there is a weakness inherent in the BPS lobby’s argument that a ‘paradox’ exists between, on the one hand, “improvements in healthcare and objective measures of health” that they assert proof that ‘everyone is getting healthier’ and on the other the ‘mysterious’ rise in long-term illness (Waddell and Aylward, 2010). Data has long been available to governments, and indeed has often been uncovered by their own commissioned research, on the differing effects of work on health according to occupation (Jones, 2001) and consequently the unequal distribution of health benefits with regard to work. Substantiating the existence of a “class-related health gradient”, evidence from government commissioned reports from 1980 and 1998 (Dept of Health and Social Security, 1980; Acheson, 1998), testifies to continuing, and increasingly marked, disparities in health between socio-economic classes differentiated by occupation. The difference in incidences of disease between those at the top of the occupation hierarchy and those at the bottom were shown to be significant, the likelihood of male professionals contracting a long-term illness between the ages of 44-64 stood at 17% while for those in the lowest group it was 48%. The falling death rate was also shown to favour the higher classes, with a greater number surviving until retirement age. This faster decline in mortality rates among the better off has continued with a widening of disparity between highest and lowest on the occupational scale. In the 1970s mortality was twice as high for men at the lowest end than at the highest, growing to three times higher by the beginning of this century. All the more surprising, then, to find the esteemed professor Aylward declaring in 2006 that though “some jobs are still poorly paid, toxic and unsafe…there are fewer of these jobs now than there were 20 years ago” (Brindley, 2006). This astonishing inversion of fact is all the more alarming considering Aylward’s extended career in government office since 1966; as chief adviser, medical director and chief scientist to the Department for Work and Pensions (Basini, 2004); one which surely must have brought him into frequent contact with these facts.

Within government discourse ‘Work’ features only abstractly, functioning as a ‘glittering generality’ in that it is vaguely, if at all, defined, and afforded only positive value. Abstract concepts, as Orwell stated (1946), can have many irreconcilable meanings, and consequently, he contends, the simplistic statements that contain them, such as ‘Work is always good for you’ are very rarely employed without the intent to deceive.

Despite the government’s reluctance, or, more accurately, refusal, to elaborate on their concept of work (Grayling, 2011), aside from ascribing to it a universally positive value, there is a very specific construction of it within official literature. Analysis of the level of ‘capabilities’ which government perceives as required to sustain a worker in employment reveal an astonishingly narrow conception of the modern workplace or of the conditions that workers are likely to encounter or need to withstand. In light of the foregoing evidence that a large sector of the workforce is compelled to work in conditions of excessive physical and mental strain it is incomprehensible to find such statements as: “Bending and Kneeling: This activity represents an unnecessary requirement for the workplace.” (DWP, 2009, p.19) This will certainly come as startling news to the veritable army of cleaners whose essential maintenance of hospitals, hotels, shops and offices, entails their employment in vast numbers, or indeed others in that ‘unskilled’ quarter of the workforce for whom bending, turning, kneeling, is not merely repetitive but intensively so. Similar examples abound in this literature, some having become notorious among the sick and disabled for their facile allusions towards what work involves, such as the ‘capability’ to “pick up a £1 coin with either hand” (DWP, 2009, p.22) which tiny activity, achievable even for amputees, is then submitted towards evidence that the claimant is ‘fit for work’.

Among Atos’ training materials one specific document compares the roles of GPs/Clinicians against that required of their ‘Disability Analysts’ (Atos Origin, 2004). The GP’s described role is as would be expected, focusing on diagnosis and treatment and the formal use of their skills and knowledge, and stressing the ‘best interests’ of the patient. The literature is at great pains to emphasise the different standpoint which analysts (who are recruited from within the medical professions) must take towards their subject. It is made clear that their role is not to act as the patient’s advocate, but contrariwise, to submit them to surveillance, an activity which, by dictionary definition, carries with it connotations of suspicion. The Analyst is directed to take a very different attitude towards the patient, one which reveals a stark contrast in the way they are to be regarded and treated. The stated objective is assessing ‘functional’ capability/limitations with ‘objectivity’. The method described is one of close detailed scrutiny, attaching great importance to ‘informal observations’, and advising vigilance with respect to exposing ‘inconsistencies’ and “findings which do not indicate disease”. This approach is highly unlikely to produce the ‘objectivity’ to which it lays claim, in its biased focus on revealing ways in which the subject’s behaviour contradicts their assertions about their condition.

Similar evidence of the ‘loaded’ nature of instructions within the literature governing this process can be found on the government side, within the DWP’s ‘Training & Development ESA Handbook (2008). Blatant instructions are given to explicitly search for evidence which contradicts the claimant’s account. The discourse may be couched in the language of ‘objectivity’ but it is clearly evident what form that objectivity is expected to take, which is to minimise or play down the claimant’s incapacity. An illustrative sample can be found in this instruction from the Handbook: “Avoid making a statement such as “Can only walk 50 metres” as this may well be taken as fact by the Decision Maker or the Appeal Tribunal. Better would be; “Says he only walks 50 metres”, then give an example of what the claimant actually does, as far as walking is concerned, on an average day: “Walks to the shops and back (about 200 metres in all) but says he has to stop at least twice due to back pain”. (DWP, 2008, p.41). Here the claimant’s account is contradictorily afforded two opposing values at the same time; their own estimation when directly asked, and a competing one derived from ‘informal’ questioning about daily activities. This method bears more in common with police interrogation of a suspected criminal, when through persistent probing the subject finally displays an inconsistency which incriminates him. Though both pieces of testimony (either one of which may contain errors) are afforded authenticity by originating from the claimant’s ‘own account’ a greater veracity is ascribed to the one which can be used as evidence of ‘fitness for work’. There appears to be no equivalent instruction to garner evidence which might work in the claimant’s favour in any of this literature, neither is it implicit within the texts.

It is not only the patient/claimant who can be constructed as ‘deviant’ within this new BPS and government discourse. The traditionally sacrosanct medical authority of GPs is being undermined through suggestions that they may be prone to ‘collude’ with patients for a variety of reasons (Halligan et al, 2003b, p.19; Wessely, 2007). Advice targeting doctors charged with filling in forms for DLA/AA (Disability Living Allowance/Attendance Allowance) bears an uncanny resemblance to that embedded within the WCA and ESA regulations: “Are regular scripts being ordered?” introduces the idea that the patient can be ‘caught out’ if their medication intake is not consistent with their condition. Examples of suggested wording leave little ambiguity regarding which aspects of patient behaviour the health professional should focus on “eg rose unaided from a chair in the surgery, no bending difficulty.” (DWP, 2008b) The stubborn resistance of GPs who remain committed to a code of ethics (McCartney, 2011) which prioritises advocacy of the patient, provide something of an obstacle to the intended ‘paradigm shift’ envisaged by the lobby. Among materials aimed at removing this include those which caution them against making ‘false attributions’ of illness to work (Waddell, 2006c), or contend that “sick certification is a major therapeutic intervention“, and play on the idea of a benefits “culture” (with accompanying stereotypical cartoon), the latter form of construction as has been described, being frequently deployed to ‘blame the victim’. The shift that they seek to bring about in general practice is a transformation away from the notion that “Work is a risk, and potentially harmful” towards “Work is healthy, and therapeutic” (Waddell, 2006c).

A noteworthy feature of the BPS lobby is the opportunistic aspect of their methods, drawing alternately, and selectively, from the fields of medicine, sociology and psychology those elements which best suit their purpose. The authority historically bestowed upon bio-medicine is drawn upon to underpin the legitimacy of their point of view – they are ‘experts’-

a presumption underscored by their frequent holding of titles such as ‘Chief Medical Officer’, whether in the public or private sector. This is the full extent of bio-medicine’s usefulness to the lobby as, outside of that legitimising function, they are at pains to present it as an inferior ‘model’ of modern illness. Concepts from sociology such as ‘illness behaviour’ and ‘the sick role‘ are deployed to support the idea that there are ‘gains’ or ‘rewards’ associated with being ill. Conscious, no doubt, of the social unacceptability of the suggestion that all sick and disabled people are malingerers, there is then the attempt to construct a ‘softer’ variant of the illness deviant via psychology. This individual is more by way of being an ‘accidental’ malingerer, subject to a form of self-deception, in which they harbour ‘irrational’ beliefs about their condition, and how it affects their ‘functioning’ or ‘capabilities’. This deviant also holds similar mistaken attitudes towards work in that they make ‘false attributions’ towards it as the source of their illness or potential cause of further suffering, and fail to realise it is the only means by which they can heal. Once these have been posed as the ‘problem’ and ‘solution’, a process in which sufferers are invariably found ‘fit for work’ can justify a snatching away of the crutches of benefit support through a doublespeak discourse reframing such support as ‘abandonment’ and redefining this actual form of abandonment as ‘rescue’.

This peculiarly  ‘messianic’ use of the concept of work, and the explicit bias of the WCA, with its excessive numbers of the sick ‘found fit’, has prompted some disabled activists to resort to parody, through an irreverent depiction of the ‘miracle cures’ of Atos (Atos Miracles; Holmey, 2011). It is through a more sombre parallel, though, that the harmful and defamatory nature of the BPS lobby’s material can be exposed. Those activists who have adopted the symbol of the ‘Black Triangle’, with its connotations of a sick and disabled community that were vilified through their depiction as arbeitsscheu (work-shy), also remind us that a means by which that regime concealed their abuses was through an emphasis on the idea of the supposedly ‘liberating’ potential of work. The most deplorable aspect of the dominance of this official discourse has been the way in which it works to conceal the real nature of sickness and disability, and the hard work that sufferers must already do to bridge the gap between their impairments and an involvement in everyday life which the able-bodied take for granted. But it is a discourse, hopefully, whose days are numbered as increasing numbers of that community ‘find their voice’ (Marsh, S; Campbell et al, 2012) and assemble themselves around a counter narrative which promises to shatter the grievously false image which has been imposed upon them.


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Basini, M. (2004) Western Mail, Cardiff, 12 July.

BBC News (2011) Grayling quoted in ‘Benefit applicants – ‘75% fit to work or drop claims’. BBC News [online] Available at: (Accessed: 30 December 2011).

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1 Accounts of deaths and suicides directly connected to Atos Assessments:

Scotsman (2010) ‘Author’s suicide ‘due to slash in benefits’. The Scotsman, 23 July. Available at:

Black Triangle Campaign ‘Calums List – NOW 17 DWP “Welfare Reform & Unemployment Deaths”. Available at:

Anderson, G. (2011a) ‘Stress of Tory benefits killed our dad, family claims’. Sunday Mirror. Available at:

Gentleman, A. (2011b) ‘Atos case study: Larry Newman. The Guardian, 24 July. Available at:

Gentleman, A. (2011c) ‘The medical was an absolute joke’. The Guardian, 23 February. Available at:

WhyWaitForever (2011) ‘DWP ESA Medical Examinations’. Available at:

(All Accessed: 04 January 2012).

2 The ‘friending’ system of social networking has facilitated the growth of groups which are accumulating condemning evidence against the WCA. Numerous dedicated blogs and forums testify to the considerable, and increasing, need it has created among the sick and disabled for support and advice. A corresponding amount of ‘real-world’ activity is also occurring as sick and disabled people have ‘taken to the streets’ to try and highlight the adverse effects of the benefit changes (benefitsclaimantsfightback, 2011), though these actions are seldom reported in the mainstream media. All in all a substantial social movement is taking shape, whose participants are, understandably, aggrieved and outraged at the government’s actions.

Reports by charities, and advocacy groups, including the Citizens Advice Bureau (Royston, 2011), those representing specific conditions, and regional organisations testify to widespread suffering of the sick and disabled who have been wrongly assessed as able to work. Some agencies have been overwhelmed by the volume of people seeking aid and requesting representation at tribunals (Independent Resource Centre, 2011), leaving some people with nowhere to turn for help. The WCA also drew strong criticism from the Work and Pensions Select Committee (HOC, 2011), where many of its systemic flaws were highlighted, and from Professor Paul Gregg, one of the architects of the new welfare system, who has called it “badly malfunctioning” and “a complete mess”.


85 Responses to Illness as ‘Deviance’, Work as Glittering Salvation and the ‘Psyching-up’ of the Medical Model: Strategies for Getting The Sick ‘Back To Work’.

  1. Steve Arnott says:

    What an excellent article. There’s so much in this I’ll have to read it over again to do it justice.

    But in the meantime, can someone print out a copy and slap Ed Miliband in the face with it?

  2. Alan Sharples says:

    A well-written article Gill. Well argued, showing extensive research. I hope it can reach lots of people.
    Its a small thing, but I do like sub-headings. Feel free to tell me to get lost!
    I couldnt’ve done it. Well done.

  3. Gill says:

    Thank-you Steve and Alan 🙂
    Agree with you on the sub-headings. Crying out for them, really, with the length of it.
    Was just that it turned out much bigger than I intended, took longer than I intended, and
    with the deadline coming up I didn’t have much left to give to it. Good job Joanne put
    some images in there to break it up a bit!

  4. Pingback: The ‘Psychologising’ of Illness and The Sanctification of Work « downwithallthat

  5. Paul says:

    Many ages ago, in the golden years of the eighties when we still had free tertiary education, a real National Health Service and so on, I remember discussing Right to Work marches with a retired railway worker friend of mine.

    He stopped me in mid sentence and said “when are the left going to get their act together and fight for the right NOT to work.” I’ve thought about that ever since.

    I would agree with the proposition that everyone should make some form of contribution to society if they can, and if the right kind of jobs are available, but work is not ALWAYS good for you and we should take this calvinist nonsense head on.

    Work as a City Banker is probably very good for you – to the tune of many millions a year. Working four 12 hour continental shifts in a week stacking shelves for an exploitative employer or wiping bums for a pittance considerably less so.

    When this Coalition government is effectively forcing people with mental health problems, cancer, and multiple sclerosis in to the labour market on pain of starvation and loss of their home through benefit cuts, you can almost smell the whiff of the Zyklon B.

  6. Kay Fabe says:

    Well done – this is the article that someone had to write. My only quibble is, how are we going to get the contents across to people with the attention span of Mail or Express readers? They’re the ones who really count as the DWP well knows, hence its endless crawling to them.

  7. Gill says:

    That is the problem, Kay. I couldn’t honestly write it any shorter. In order for the argument to have any credibility you
    have to lay out the whole detailed story. Maybe someone else has the skills to do that other thing. I would like to think so.

  8. Kay Fabe says:

    If we are to recommend this article to peeps, how can we describe you? We can’t just say it’s by some babe, we have to say it’s by respected researcher or qualified thingumajig, whatever.

  9. Jaki Rundle says:

    This was so interesting to read, and as a person with disability myself I must say thank-you. It is always good to have the background to these things so as to better be able to counter argue them. I am not on any work-related benefits, only DLA, and am now scared myself even with them messing with that, that ‘they’ will force me to ‘work’. I would add also too that while there may indeed be great benefits for people with disabilities to have occupations throughout the day to focus on and improve well-being. Why does the government then assume that it needs be paid work!!!! The formal working environment is not often a friendly one towards people with disabilities, no matter how many ‘laws’ (that are not upheld) the government may have about discrmination

    . Another point; the best people and ‘professionals’ to help people with disabilities in society are…… guess what: yep, people with disabilities!!! How can someone with no experience of it, ‘judge’ whether someone is fit to work or not? No matter how much training you have. Nothing about us without us!

    Ps, I agree with Paul too!

    Thank-you so much again for this. I will be sharing!

  10. Mike Caics says:

    A good thesis Gill. Illuminating and extremely persuasive. I find the whole assertion of the “Work is good for you” epithet to be similar in its overarching generalisation as “Arbeit Macht Frei.” The concept is pretty much the same – the ‘modernized’ syntax is less provocative, but no less deliberately misleading. What concerns me greatly is the purpose to which ‘BPS’ is being put. I find it utterly facile as an argument and lacking any real, quantifiable or qualitative depth – either at a research or diagnostic tool level. It is, perhaps, merely a measure of a new kind of conceit which has begun to emerge within so-called ‘new-sciences.’ The immediate limits of BPS do not seem to be stated anywhere, and many of the weaknesses, based on ‘observational, behavioural or clinical’ diagnoses and/or psychological examinations are not examined in any detail either. For instance: the ‘tools’ that have been employed to contradict or counterpoint an individual’s claim to illness are only stated in their most positive and self-affirming light. Yet, as has been found in those who eg. suffer from psychological syndromes – the closest observation etc has little or no effect in allowing diagnosis, as the syndrome only effectively shows itself in high stress conditions or conditions where the sufferer is exposed to a negative stimulus which triggers their response. The deliberate delineation, and, one might argue, over-simplification of illness, whether through disability, work related stress or aging, has allowed the crypto-scientists to proffer trite and condescending ‘reasons’ for ‘commonly felt illnesses.’ Teh danger, however, is that this oversimplification has also given rise to a level of scientist-led contempt for those who are afflicted by illness. From there, Government backed and (consequentially) authorized publications and a raft of rhetoric clad, pseudo-intellectual assumptions have been characterized as ‘Scientifically-Proven.’ This is the diet which has been spoon-fed to the General Public via both the Media and the Press. Unfortunately, due to the establishment of a significant amount of ‘published nonsense’ giving all manner of reasons and explanations about “why people are sick” – “faking, malingering and the undeserving poor” – it is difficult to take action head on. Colliding with the ‘brain-faeces’ of eminent Professors of Witchcraft and Scientology is about as far as anyone would get. I firmly believe that the only way to discredit all of the pompous, crypto-intellectual, unfounded and unproven rubbish written by the above authorities is to show, not through QED, but through already established foundational scientific principles why just so much of the work done both by vouchsafe and de facto advocates of UNUM, ATOS and the truly excremental (and not wholly discredited malignant narcissist) Ian Duncan-Smith et al is just a load of publicly paid for “guesswork..”

    It is not merely the articles, the literature, the purported research nor even the emminence of the writers that must be wholly dismissed. Better to attach the real purpose of these assertions. Government and UNUM/ATOS etc are simply out to make money from the dispossession of the infirm. My own thoughts are these: “One does not need crematoria, concentration camps or forced labour under the sigil of the Swastika when one can pursuade ones own countryment to demonize and assault the weakest, most damaged and distressed, forcing them (through the imposition of Legal Obligation and Popular Policy) to undergo public humiliation in the guise of 21st Century poverty and destitution. They will undoubtedly choose their own destruction rather than live in a seemingly ‘twilight existence’ that repeatedly robs them of any opportunity for the barest graces of any kind of ‘normalcy.’ In the instance of individuals ‘choosing’ to end their lives rather than live to the constant beating of a hollow drum marking the slow and inexorable descent into public contempt and social obscurity, then neither Government nor the wider public can be blamed for the failure of a few ‘unproductive’ human beings, unable or unwilling to seize the opportunity to better themselves through a positive, affirming, work ethic. Better still if those affected (the impoverished) can be “allowed” to dispose of themselves in the manner they see fit. Rather than have a state-agreed methodology of driving the disabled and mentally afflicted to self-destruction, it is better that the pressures of their existing and (one would logically assume) developing circumstances (ie. circumstances which underpins the ‘certainty’ that have or that they are about to lose much of the money, provisions, state aid which provided for their limited independence) might contribute to an immediate decision to self-terminate.”

    This is made worse when I assert the contrary statement “Work does not do you good. In fact, all forms of ‘slavery’ are damaging to the health of the individual. All Work does, is to create more work. Work makes Taxes.. THAT is the only truth!

  11. Gill says:

    Yes, Mike, its not for nothing that the disabled are adopting the discourse of the Third Reich to illustrate their plight. Its just the most apt parallel to draw. I liked your designation of the “Professors of Witchcraft and Scientology”. Their ‘Medically Unexplained Symptoms’ theory is so baseless within contemporary medicine that they have had to go to the lengths of digging up Freud, with his discredited (and initially misogynous) notions that people are prone to ‘hysteria’. But just in case that doesn’t wash they have to pull in the idea of the ‘sick role’ from Parsons. I don’t think I’ve seen such a blatant abuse of the social sciences, which by their nature are susceptable to being used for good or ill.

    From what I can tell the ‘Work is Good For You’ assertion (solidly embedded in all government policies since) originates from that one single literature review carried out by Waddle and Burton in 2006 from within the Unum funded centre at Cardiff. It forms the only justification for these ‘work-as-welfare’ policies, and it is baseless, since it seeks to generalise about an undefined, undifferentiated, abstract idea of work. That is, it does not distinguish between the experience of work (and the benefits that accrue thereof) to an ‘esteemed’ university professor (or Chief Medical Officer of this or that) and that of someone who cleans for him, or prepares his food, or cares for his elderly relative. Anyone who has studied for a social science qualification knows how easy it is to make a literature review look authoritative while omitting any material which contradicts your argument. (So sad about that, as I do love those sciences…, and hate to see them misappropriated in that way).

  12. Gill says:

    Kay, lol at ‘babe’:D
    I have myself described on Academia.Edu as an ‘Independent Researcher, Social Sciences’.
    So I suppose that’s what I am 🙂 I graduated with a degree in Social Science in 2010 (1st Class hons – if that helps bump up my status any ;).
    Social Science includes Sociology, Psychology and Social Policy, bit of Criminology as well, so its a good one for ‘overviews’ of a situation.
    It’s a good discipline for nitpickers, I highly recommend it!
    Sorry I haven’t got any publishing history or anything so far, apart from my blogging on this topic at ‘downwithallthat’.
    But yeah thats about it.

  13. Gill says:

    Jaki, its astonishing the lengths that the government (and their compliant news media) are prepared to go to silence the ‘cries’ of the disabled. Once again, as a social scientist, I am appalled at such things as the misappropriation of the term ‘demonisation’ by Emily Maitlis (in interviewing Sue Marsh on Newsnight) to suggest that this is what is being done to the government by activists! Last time I looked the term is usually applied to describe a process whereby a minority, powerless group are ascribed negative characteristics by a more powerful group in order to facilitate their persecution. The government are a minority? Powerless? Ms Maitlis seems to have an extremely warped view of how power is distributed across our society!
    Similarly, ‘Lord’ Freud referred to the governments actions as having been ‘grossly misrepresented’ by disabled activists. Despite all the increasingly stark evidence to the contrary!? The government it seems are now to be portrayed as ‘victims’ by themselves and the media. How ironic, how ‘blackwhite’ and ‘doublespeak’ of them.

  14. malka says:

    wonderfully written piece, very scary though for all sick and disabled people now in the UK, as a carer i try and protect the person i care for from the reality of this morally sick government…………..but deep down i fear for the future of all “non-taxpayers” as the government views those who do not work…i compared this regime to the nazi germany a long time ago, and unfortunately it is coming to pass……………

  15. Lesley says:

    Fantastic piece of work. I am undertaking a PhD on the “discourse”(in the Foucauldian sense of power/knowledge) surrounding ESA and the actual effect on sick/disabled people…this will also look at the counter-discourse in the campaigns you mention. I have picked up on many of the same themes as you…it is good to know that I am not out on a limb. Some critiques on ESA still focus on the medical v social model of disability but this is not helpful for this purpose. As you say this discourse will opportunistically latch on to anything that suits the purpose even bending the SMD (taking in many who should have known better under Labour initially). What you call the “medicalized bureaucracy”-I think I used the same phrase-is given a a medical gloss and perceived legitimacy when in fact GPs Specialists and therapists’ reports are taken out of the equation. The “experts” are so tied up with the insurance and finance industries, their medical labels are just a smokescreen. You have given me so much to think about…Thankyou

  16. Sam Barnett-Cormack says:

    The line now is not “Arbeit Macht Frei”, but “Arbeit Macht Gesund”. It is treated like some holy mantra, and they’ve even been trying to push that into the regulatory rules for how doctors should work generally.

  17. Bluesky says:

    Gill, what an excellent but very scary article! I’m so impressed by all your research and hard work on this; as an ME sufferer I’m all too well aware of the problems that Mr Wessely and his ilk have caused, and are still causing for us all.

    I’m going to have to lie down now, as my irrational illness beliefs have kicked in…..

  18. Gill says:

    Lesley, so pleased to read that you’re doing that for your PhD! We have both endorsed each other there, I think. Its good when you find someone else is working along the same lines. Yes, those opposing discourses! So much there to work with, academically. They couldn’t be more different. I loved it when we ‘touched on’ Foucault at uni. I was desperately trying to read more of his stuff as we swiftly moved on to something else 😦
    He’s becoming ever more relevant these days with all the ‘self-disciplining’ people are exhorted to do etc, new methods of surveillance that are increasing, and so on. I’m happy to think that my material has encouraged you. Best of luck with your study, hope we can see the results sometime in the future!

  19. Gill says:

    Sam, yes I agree. So much that I wasn’t able to cover fully in this piece, such as the constant pushing of the ‘therapeutic value’ of work etc by this lobby. I did touch on how they are trying to ‘convert’ GPs over to this way of thinking. All part of the ‘campaign’ 😦

    In my reading around I got the impression that some doctors suffer frustration over having patients that they can’t seem to help, the BPS lobby’s ‘medically unexplained symptoms’, but really have only got the word of the lobby for that. They are obviously trying to play on that with doctors, put it to them that they are doing their patients no favours by ‘signing’ them off sick. That’s a piece of research that is crying out to be done – Do GPs really feel and act that way? If Margaret McCartney is anything to go by they are fiercely protective of their ethical responsibilites, so I can’t imagine them writing sick notes if they feel the patient would be better off in work. So I am fairly sceptical of that notion tbh. I should expect, rather, that GPs would be offended at the way they are portrayed within the BPS lobby’s discourse. I know I would be.

  20. Gill says:

    Bluesky, I was appalled to discover what they have been doing to the M.E community for so many years. Its nothing short of legitimised abuse. The one discouraging thing I’ve experienced in all my research so far has been discovering, for how many years, how much authentic evidence has been simply disregarded by those in power in favour of this spurious psychological approach. Some of the accounts on the net are simply heartbreaking, and it beggars belief that these people should have been allowed to continue with their ‘methods’ and ‘theories’.
    As someone pointed out recently they ‘intervene’ in people’s lives with impunity, disregarding their negative effects, for which they are never held to account, and quickly move on to something else (as Wessely did in moving on to Gulf War Syndrome, another topic that evidently held the potential for his psychological ‘quackbuster’ approach).

    “Professor Wessely should be granted a dictionary of his own, so
    far has he stretched the meaning of the English language while
    attempting to explain that ME although a ‘real’ illness, is often first
    imagined. He has trodden the tightrope of confusing semantics with
    the balance of Blondel and the focus of a train spotter.” – Martin J. Walker

    In Wessely’s World we’re ALL potential hysterics. Excluding himself of course. Though its evident from his over-reaction to legitimate criticism that his particular psychological susceptibility is to a persecution complex. Ironic.

  21. Patrick says:

    I’m unconvinced by this article. It is well written but I’m not sure you can argue that benefit reform is a blind ideological attack on the poor and sick when the UK is bankrupt and almost everyone knows people on the dole who are capable of working. My grandfather was a Labour councillor and died very disappointed in how the benefit system was being taken advantage of. He never envisioned it being so widespread and crowding out charity, family and community care responsibilities like it has.

    Undoubtedly there are problems with education, healthcare, food and nutrition. According to my understanding an education and healthcare voucher system would do a lot to help this. What are your thoughts?

  22. Gill says:

    Ah, Patrick, my first dissenter. I’m just off to bed but I’ll give what you’ve said some thought and get back to you 🙂

  23. Gill says:

    One last thing for now, because I’ve noted that one or two people have described this as scary (malka, Bluesky), and I didn’t want to add to anyone’s worries when they’re ill or caring for someone.

    Its taken me a year of quite intensive research to reach the conclusion that I have in this piece. At first, like a lot of people do at first, I thought that Atos were the problem. And what you perceive to be the problem dictates the action you take. So the way this has materialised, and it is so widely applied now, is campaigning around the issue that Atos are inefficient, that the WCA is ‘flawed’ etc. This is quite a safe idea for government, as it limits their responsibility to ‘tweaking’ the instrument within pretty much any timescale they please, or ultimately getting rid of Atos, only to replace them with an identical company who administer the same process, unchanged.

    Its only through looking beyond the instrument to the actual ideas that have shaped it, and the people who have been involved in that process, that we can get the measure of the real problem, and perhaps channel our energies more effectively against it. The task is to discredit this group and their theories as they have attempted to discredit the sick and disabled. It might seem daunting, but it has to be a more promising strategy than what could prove to be the somewhat hollow victory of unseating Atos, or having some minor adjustments made to the WCA/ESA.

  24. Gill says:

    Ok Patrick, you kept me up. I wouldn’t have been able to sleep without addressing what you said,. but I’m only going to do this once, in case anyone else decides to take that position:

    This assumption that the country is ‘bankrupt’ is not a proven assertion by any means, as has been comprehensively demonstrated at, who examined Johann Hari’s piece “The Biggest Lie in British Politics”, and at several other legitimate economics sites on the net. The lie being that this current level of debt is high either by our own historical standards, or in comparison to other countries, such as Japan (“national debt three times bigger than ours, and still borrowing at good rates”.) The question has to be asked Patrick, whose version do you trust? Nothing I say is likely to change your perspective if your preferred source of information is the government.

    Similarly if you are convinced that people are fraudulently claiming benefits you might want to research the widely available statistics which estimate (and it can only ever be an estimation, by the nature of the beast) a very, very, very low percentage of this in the area of health-related benefits (Iain Duncan Smith has recently stated this himself!). The reason for this is that, counter to what you might have been led to believe, this country already had the most stringent process in Europe for evaluating people’s entitlement. I know, surprising isn’t it? But that fact from authoritative sources is also available online.

    With this in mind, and by your conceding that my piece is well-written, backed up as it is by a comprehensive raft of references as evidence, I don’t understand why you remain unconvinced by my argument.

    You seem to be adopting a somewhat emotion-led stance on the subject, informed as it is by your grandfather’s disappointment at what he perceived to be abuse of the system. And what you appear to be saying is that because ‘everybody knows someone who is capable of working’ it is morally acceptable to cause widespread suffering to a vast percentage of the legitimately sick and disabled community, forcing many into destitution.

    I haven’t covered the issue of lack of jobs in my article because it was less relevant, but just because someone is ‘capable’ (and I’m talking about those who are actually ‘fit’, not those processed by Atos of late) of working does not mean they are automatically able to find work in this climate. Check out the figures, Patrick. Its not how it was in your grandfather’s time, jobs are scarce all over the country. But what I did cover is that the quality of a large proportion of those available jobs has deteriorated. There is uncontrovertible proof of that which has been produced by legitimate academic work. And it is clearly a cruelty when the government acknowledges that it is forcing sick people into jobseeking (“they may be sick, but they can do ‘some’ work” is the mantra) when the conditions they meet are likely to exacerbate their illness. Are you not outraged at this idea?

    I have also, I feel, convincingly exposed a deliberate campaign by a very small group of men, with seriously dubious connections to a private insurance company which seeks to profit from our welfare system, riding upon their official statuses, who are working to discredit the genuinely sick. I think I have provided enough material to make this case strongly enough. Its hard to see what you find unconvincing about it. But as I said if your preferred source is the government then no alternative ideas are going to persuade you.

    As to your idea for a voucher system I don’t know what that would involve other than a way to ‘micro-control’ the behaviour of those in receipt of welfare, by directing what and how they ‘consume’ in various areas of life. I find that an idea best suited to a totalitarian system, and that it also hinges on an idea of those in receipt of welfare as untrustworthy, a notion that this article disputes. Also, finally, I do not know anyone ‘on the dole’ who is capable of working that wouldn’t jump at the chance of a decent job with decent conditions. There, too, if you choose to research such authoritative sources as the Joseph Rowntree Foundation, or simply google ‘working poor uk’ you will discover the extent of impoverishment that afflicts masses of working people in this country today. Can you read all that and still say you believe the government when they assert that work is the solution to the sick’s problems?

  25. Joanne Telfer says:

    Absolutely brilliant Gill. Not only have you written an astonishingly comprehensive article on the subject at hand but you can explain your ideas so very effectively to those who doubt the whole legitimacy of your thesis. I’ve experienced ATOS so I need no convincing. I am to a certain extent on probation for having opened up this website to new contributors. Your piece is intellectually challenging in its depth of analysis but I knew straight away that you saying what many of us were thinking but unable to express so well. Perhaps I can twist your arm and ask you to comment on other articles within this issue. I’d certainly like to think that you will continue your association and write for us again in the future.

  26. Patrick says:

    Point 1: The difference between the UK and Japan is that Japan’s debt is mainly owned domestically, so their debt market is a closed loop. Also Japan runs a massive trade surplus every year. Their inflationary cycle in the 1980s was driven largely by the manufacturing sector which led to over-investment in factories. This, however, had some external benefits, much like the technology boom in the West in the late 90s, that created a platform for further growth. The West got the internet, Japan got a strong manufacturing base. Britain’s inflationary cycle led to financial fraud and home improvements. There is nothing left of value to show for our inflationary cycle, only a black hole of CDS fraud, market manipulation, war and empire. Japan, at least, had factories which allowed it to muddle through the next 20 years.

    Also, Japan has relied upon 0% interest rates for 20 years in order to keep its debt payments down. This causes problems with malinvestment and the capital structure of the economy. And the longer Japanese debt keeps bulding, keeps being rolled over the less likely it is that either the interest rate or the value of the currency will remain tenable.

    Point 2: I don’t doubt that there are many legitimately sick people who are suffering. This is why the system needs to be reformed. The most deserving need to get the most support and support needs to be individually tailored. Right now they aren’t and it isn’t. It would be nice to at least acknowledge that something does need to be reformed. We need increases in outcomes not necessarily increases in spending, and to better define in society what we want those outcomes to be. Anyone can argue that they are suffering from a money shortage. There’s always ‘something’ that someone doesn’t have ‘enough’ of.

    Point 3: I don’t doubt that special interests are at work. Of course they are. This is a democracy. Businesses are working within the incentives given to them by the democracy. Their benefit is concentrated while our detriment is diffuse. Market failure doesn’t stop with government… in many cases it can be much worse. Maybe you could think about what it would take for businesses to spend more time catering to the average guy than catering to influence the government. They aren’t going to go away.

    Point 4: I agree with you with the jobs situation. I definitely agree. The jobs situation is shocking, especially for the young. The welfare debate is only useful in the context of the job market. The market was very different in my grandfather’s day that’s for sure. It’s funny that taxes were also lower and the state smaller. I still struggle to square that circle. Maybe you could help?

    Overall I think that politicians should be commended for at least recognising a problem and attempting to tackle it in a way that doesn’t just throw more money at it. The debate, for me, should not be ‘whether’ reform is necessary but ‘what’ reforms are necessary. I think you will have more leverage in the debate that way. All the ‘working’ class people I speak to: joiners, plumbers, hairdressers, shop-keepers are largely fed up with seeing people on benefits who, they believe, can work doing better off than they should be. Just yesterday my hairdresser was talking about people on her street who don’t work but can afford to run two cars. Both she and her husband work full time and they can’t. The perception is prevalent that the welfare system isn’t working in its current form. Trying to argue otherwise is swimming against a tide of strong opinion that is only going to get worse if the economy keeps shrinking and taxes keep going up.

    I value your assessment of the problems currently faced by the proposed reforms. However I don’t see the status quo as tenable.

  27. joe kane says:

    “I’m not sure you can argue that benefit reform is a blind ideological attack on the poor and sick when the UK is bankrupt…”
    – Naomi Klein invented an excellent phrase which describes this phenomenon, called “the shock doctrine”, where those in power take advantage of a real or imaginary crisis to ram through policies which would otherwise be unacceptable and rejected by the public at large.

    “…and almost everyone knows people on the dole who are capable of working.”
    – With nearly 3 million officially unemployed that should come as no surprise to anyone.

    “I don’t doubt that there are many legitimately sick people who are suffering. This is why the system needs to be reformed.”
    – It’s the reforms that are making them suffer.
    How do you tell legitimate from illegitimate? Claiming there is any such problem is the language of the neoliberal reformers.

    “My grandfather was a Labour councillor and died very disappointed in how the benefit system was being taken advantage of.
    – It sounds like your grandfather should have been even more disappointed with the introduction of neoliberal economic policies designed to keep millions unemployed. If he was a real socialist that is what he would really have been complaining about.

    All the ‘working’ class people I speak to: joiners, plumbers, hairdressers, shop-keepers are largely fed up with seeing people on benefits who, they believe, can work doing better off than they should be. Just yesterday my hairdresser was talking about people on her street who don’t work but can afford to run two cars.
    – If anyone has any knowledge of the law being broken then they should report it to the authorities. People who know of criminal activity but don’t do anything to stop it are no better than the criminals themselves.

    What do these ‘working’ class people say about the £35 billion in taxes that goes uncollected by the government, which some estimates put as high as £130 billion? Or the nearly £1 trillion in British taxpayers money that disappeared into the coffers of bankrupt financial companies and failed banks?

  28. joe kane says:

    I did mean to say that I agree that the benefit system isn’t working properly and needs reform. It needs reformed away from the brutal American-style state authoritarian system being introduced which is used against those out of work who are made that way by neoliberal economic policies.

    Blame the unemployed. Blame the poor. Even blame the chronically sick and disabled. But don’t blame decades of government policy which is now taking advantage of the weak and the powerless to blame them for the failings and problems created by neoliberalism..

    Given that hard-working taxpayers in their time of need, when they become unemployed are given next to no advice by the DWP and are largely ignorant of their rights when they become unemployed, sick or disabled it is no wonder £16 billion in benefits goes unclaimed. There are estimates that £66 billion goes unclaimed across all types of welfare benefits. All Grayling and Smith can do is complain about a measly £1.2 billion in DWP fraud, which is less than the £2 billion in DWP errors and inefficiencies. I see Grayling was even whinging on about immigrants on welfare the other day.

    Department for Work and Pensions: 2010-11 accounts
    National Audit Office
    19 July 2011

    Charities challenge government over £16bn unclaimed benefits
    Citizens Advice
    03 Feb 2010

    Stop Bashing Benefit Claimants when £66 billion goes unclaimed per parliament
    Green Benches
    03 Nov 2011

  29. David says:


    “I don’t doubt that there are many legitimately sick people who are suffering. This is why the system needs to be reformed.”

    No it is not, but it is reason why the current changes should be reveresed as they are suffering a LOT MORE now than they were previously. Has it not sunk in that that’s what disabled activists and charities are saying? Funny how you’ll take the “suffering” argument but distort it into a meaningless phrase to justify your fears rather than look at the reality of cause and effect and consider that maybe, just maybe, sick and disabled people might be best placed to say whether their suffering is greater or less now and what should be done about it.

    Sick/disabled people should have been specifically canvassed at grassroots level rather than treated as a “thing” to be solved because only a fraction are genuine, supposedly — pretty offensive stuff to the community they’re doing a big pretense of wanting to protect. Protection and an economic model of disability do not mix. Yet all the main arguments are based on cost, only the feeble defences based on claims to protect (an afterthought). Cost is never altruistic.

    Where is the evidence that disabled people are being failed to such an extent by the existing system that they want “reform”, rather than better enforcement/quality control of existing systems? Where is the reform of ATOS? Even if people do want something they would call “reform” (which they surely wouldn’t since it’s a transparent euphemism for “restriction”) it probably wouldn’t consist of a priori bumping 2M disabled people off the figures. You assume far too much.

    “The most deserving need to get the most support and support needs to be individually tailored. Right now they aren’t and it isn’t.

    Says who and if they do, who says this is the solution. Why do you assume that the people speaking against these “reforms” are not already among the “most deserving”? Have you not heard that ESA has been a disaster, charities swamped with shocking, wrongfully denied cases, a massive backlog of appeals and all the rest. And this is your idea of tailored support?

    Problems with DLA not accounting for fluctuating conditions don’t justify (the huge costs amongst everything) of binning it. The level of fraud is tiny due to it’s tough assessments and what’s more, since people are allowed to work and get it, they can help cover the cost — though in reality it’s so tough to get, the assessors so idiotic, I don’t think the number of those working with it is big.

    “It would be nice to at least acknowledge that something does need to be reformed.”

    Nice for who or what, daily-mail-esque paranoia about lead swingers stealing taxes. How about it would be nice to acknowledge the need of a one-off wealth tax that would solve the UK’s difficulties quickly easily and painlessly — so painlessly some of the wealthiest 10% have even recommended it. But I guess there’s not much righteous schadenfreude in that for the middle classes.

    Yes actually, something does need to be reformed. The cult of misinformation and ignorance surrounding disability in the UK needs reformed. Corprorations that avoid paying tax and the system that permits this need reformed. The lazy, disablist, partisan media needs reformed. An economy dependant on private banks with their arbitrary virtual money that necessitates debt and endless inflation, needs severely reformed. The cozy symbiotic parasitism between the state, insurance, rehabilitation and disability assessment companies (eg ATOS) and psychiatry, “the hired guns of the insurance industry”, needs reformed.

    Or rather, they need to be dismantled/booted out and replaced by something much better. The much better ideas are all out there (might be a bit hard to find due to the media’s phatist philistinism) but they’re a bit scary to the State and it’s pet phobic apologist little Englanders.

    “We need increases in outcomes not necessarily increases in spending”

    Social services or their cheap agencies have their hours slashed and get told to do the same amount in half (or less) the time; the only increased outcome there is in absurdity (and suffering for clients including increased hospital use and stress for employees), but that’s where ultra-severe policy aimed at the vulnerable takes you.

    Corporations and banks definitely need to increase spending (ie be taxed more, more efficiently and to lose all awards and much of their profits) to pay for he damage they’ve done. Instead they get a get-out-of-jail card as they’re too “important”. (WTF.)

    If the government had the power to create it’s own money there isn’t generally a need for increase in spending. You only create money (real money not fake virtual money) for essential projects, doing so doesn’t hurt anyone because it’s not a debt and it benefits everyone as it circulates. This is the only long term solution that benefits everyone, for governments to take back control from the banks, make money the slave and society its master.

    “Anyone can argue that they are suffering from a money shortage. There’s always ‘something’ that someone doesn’t have ‘enough’ of.” ”

    In view of the topic revolving around disabled people who by definition have increased NEEDS and where they’re not met, suffering, I find that a somewhat ugly assertion. Clearly your cognitive dissonance is so immense none of this is getting thorugh — the fact that the poorest, sick and disabled are suffering most; which has always been the case down through the ages but should now be inexcusable. Now you have no qualms about traducing the importance of this dialogue by implying that people are just whinging about not having the latest mobile or cable TV. Utter shame on you.


    Thanks for the great blog Gill. You covered a lot of important interwined stuff that virtually never gets an airing above grassroots (easily dismissed) level, and very eloquently. The big corporate disability charities don’t seem to like this degree of critical thinking; I guess they know which side their (financial) bread is buttered. It’s taken a lot over the last several years to push some bodies to complaining.

    I think Patrick may be too stuck in his rigid preconceptions of the poor and disabled (evident from fequent “diminishment” arguments that imply a lack of genuineness among disabled people evidence of which exists only in the tabloid/right wing press) to ever change — unless he were, god forbid, unfortunate enough to see life from the other side. And everyone with disability is deserving, there is no-one “not” deserving. That’s like saying some blacks or gays are “most deserving” and some aren’t. Offensive drivel.

  30. Gill says:

    Thanks Joanne 🙂
    I’ve had a lot of positive responses, here and on facebook. Good to know that I’ve been able to communicate something clearly!
    I’ll certainly try and contribute to other articles. Brain needs a bit of a rest at the moment, as I’ve spent all day responding back to
    people and such like. Also thinking about where I want to go in taking this material further. But yes, I’ll try and participate as much
    as I can 🙂

  31. Gill says:

    Thank *you* David, and Joe, for relieving me of the obligation to respond any further to Patrick. I would just add that examples
    that he’s given of ‘sources’ for his argument, being anecdotal and of the “I knew a man…” type, offer little to substantiate his
    notion that neighbourhoods are crawling with 2 car scroungers etc. I come across people quite often who have these ideas and
    inevitably they “know someone who knows someone” who says…

    Sadly they would be better informed about this situation, that of the sick and disabled, if they went to the trouble of asking *them*
    directly about whats been happening to them. I think they’d be quite shocked at what they would learn. But that, of course, might
    threaten their fondly held, comforting world view that “everything in society is proceding as it should”.

  32. Patrick says:

    I think I agree with most if the problems people cite. However I think it would be more useful to separate the issues of tax, neoliberalism and welfare reform for now. It’s getting a little off-topic. I would also appreciate mention of my grandfather to a minimum. I don’t believe making unfounded statements really adds anything to the debate. If anyone wants to know who he was then by all ask but don’t judge when you don’t know anything. Must say I’m a little disappointed with some of the responses. Oh well. I suppose this is an emotive subject so I’ll it’s possible to forgive transgressions of normal social etiquette.

  33. Patrick says:

    I find this article to be valuable, however to call yourselves socialists, to call yourselves people who are democratic, to call yourselves people who stand up for the working class and then ignore the opinions of the working class and widespread democratic opinion when it is no longer convenient is nonsensical to me.

    However it is valuable as far as it goes… But its the article of an opposition movement. If you want change you need to present a vision that ordinary working class people can sign up to. There is no vision here. If you want your opinions to have any traction you need your own new ideas.

  34. Alex Young aka alex3619 says:

    This is an excellent article. I have recently drawn some of the same conclusions you have, although I am nearly a year behind you in analyzing it all. There is an important part of the debate missing though: the “evidence based medicine” movement. It is closely tied into the biopsychosocial movement, and is again an arm of government policy dictating to the medical profession. It has been called Zombie Science.

    I am in Australia but have been actively watching this encroach on the UK disabled. It is loathesome what is happening over there. I might be half a world away, and disabled myself, but I cannot be quiet on this issue. The sense of fear and bewilderment I regularly hear from the disabled in the UK is reverberating around the world.

    Those of you living in the UK might feel that you are isolated and in this alone, but if you reach out to international activists you may find global support.

    This has the potential to completely destroy the good name of the UK, – and people are already making unsavoury parallels with despicable regimes.

    One of the things that is often missed is there is a growing rise in opposition to the biopsychosocial movement, not from the disabled, but from psychiatrists and other medical professions. I am looking into this.

  35. Joanne Telfer says:

    Patrick I would recommend Robert Tressel “Ragged Trousered Philanthropists”. Please forgive me if you’ve already read it but it may go some way to explaining why there might be a difference between the author’s views and opinions that are prevalent on the street. One of the main problems with your approach is the use of ATOS healthcare a private medical agency which arranges and runs medical assessments. The system is a loaded dice which operates against the sick or disabled person’s best interests and reform is not moving in the direction of improving that situation.

  36. Chris says:

    Hi. Great research. However, though you’ve highlighted Mansel Aylward’s role in the origin of this nonsense, you’ve only mentioned UNUM once. This appalling company, with its US ban in many states on the grounds of being ‘benefit denial factories’ and refusal to pay out legitimate claims of health insurance – is now advertising in the UK ! Those who take out policies will be in for a rude shock..

    Just to briefly counter Patrick’s ‘thesis’ – yes, we need a new vision. But before that can be birthed, existing abuses must be exposed and held up to critical evaluation and if necessary, ridicule. The public simply doesn’t know the background to the welfare ‘reforms’ and websites like this are to be thanked for the work they do in rectifying this.

  37. Patrick says:

    Joanne, it’s not my approach it’s ‘an’ approach to a widely recognised problem. The fact that someone in power is recognising a problem should be commended however I recognise that this solution is very problematic. But for socialists to put their head in the sand in the face of widespread perception amongst low and middle income workers and say we just need more of the same makes no sense to me. The current system doesn’work for the sick, it doesn’t work for those who are capable of getting back to work and it doesn’t work for taxpayers. The life expectancy in some parts of Scotland is third world. These areas desperately need reform in welfare, education and economic stimulation. I doubt anything could be worse for them than more sof the same.

  38. Gill says:

    Thank-you Alex. I must look into this Zombie Science…
    Its generally said that if you want a clear picture of what’s happening in your country you should go to outside sources. I feel a sense of
    relief that this particular issue looks exactly how so many of us feel about it, when viewed from a distance. The thing about the psychology
    which features in this material is…Well let me put it this way: I have only studied as much psychology as first degree social science study
    allows (though I’ve had a lifelong interest), but in the context of that I can only describe its use by these supposed distinguished scholars as facile and backward-looking. I can not believe that the general psychiatric/psychology professions would give it any serious weight. So the only authority that it can possibly have is that derived from the positions of power that the proponents hold. It can only do the gravest disservice to those in
    these professions who are striving to improve conditions for those under their care, or undertaking genuine research to that end.
    Very glad to hear you’re looking into that 🙂

  39. Gill says:

    Chris, yes. Just yes, really. This article was originally going to be half the size, and I think some people have found its eventual length a bit daunting. I wanted/needed to be able to fully describe what I observed as the process that was going on, and back it up with a sound argument, evidence and so on. Believe me I wish I could have incorporated more about Unum into it, but I didn’t want to weaken the points I was making by throwing too much into the mix.

    Its a complex issue, with many aspects to it. Unum deserve a whole article devoted to them, one which systematically goes through their involvement (as instigators). As do Wessely & the cognitive behavioural M.E scandal, Aylward and his favouring of ‘positive psychology’ – see Barbara Ehrenreich for an exposé of that particular abberation – (not to mention his profiting financially from his involvement in the promotion of HRT treatment to menopausal women, so many of whom contracted breast cancer, and other illnesses, as a result), Waddle & his ‘signs’, the ridiculous theoretical foundations of the WCA & the ESA regs, the very notion of ‘psychosomatic’ illness, and so on. There’s so much there, and I’ve only got the one brain! But yes, that needs to be done for sure.

  40. Alex Young aka alex3619 says:

    This is a very brief intro to the idea of Zombie Science. This is a popular piece, but others of his papers are more aimed at academia. Evidence Based Medicine claims it is about better outcomes at reduced cost …who can argue with the idea of using the best evidence? However, the evidence is sometimes assembled by a rubber stamp approach using simplistic criteria … and somehow the recommendation usually matches their agenda. This appears to be a way to allow government to have greater control over medical practice. Privately I am aware large numbers of doctors are unhappy about this, but publicly they often say nothing. Unfortunately that is anecdotal – it may just be that I am only hearing about such doctors because I am looking for them.

    Evidence based medicine has never been scientifically validated, and it is deeply flawed methodologically. The rise of the biopsychosocial movement and the evidence based medicine movement closely parallel each other.

  41. Joanne Telfer says:

    Patrick I really don’t believe that the Government has the welfare of sick disabled and unemployed in mind with its welfare reforms. The Government’s chef objective is to balance the books and many of the problems that the author draws attention to have come into being as a result of attempts to cut the welfare bill.

    All this has suddenly become much more urgent as a result of an international crisis in financial markets where bank debt has been offloaded from the private sector to the public sector. We can go round and round in circles talking about public perceptions but these are conditioned by the information supplied to by the media and by gossip. The reality is that sick and disabled people are now being faced with a renewed onslaught as if things in the system were not already bad enough. You have to experience the system to see what’s wrong and the reforms which the Government has in mind are not about increasing fairness.

    Finding a way out of the current general crisis of the whole economic system demands in real terms, the wholesale destruction of living standards and huge reductions of ordinary people’s wages to make the accumulation process start again. Pushing people off sick benefit and off disability benefits is not about moving them into work, it is about increasing the potential labour supply to the point where real wages fall dramatically. A better way is possible but that will demand a new sort of society.

  42. Very nice article indeed Gill. Thank you so much for writing about this issue.

    If I may make one point – I think you have been too ‘kind’ to the biopsychosocial paradigm.

    Whatever the ostensible “patient as a whole person” or ‘holistic’ philosophy that is claimed when using terms such as ’biopsychosocial’ or ’psychosomatic’, these terms are used most often to promote an approach that assumes a causation of psychopathology and deviance, for a somatic illness, and to advocate treatment approaches based on this belief.

    Indeed, Engel does not address the issue of psycho-social impact of illness at all, but instead argues that ‘psycho-social’ factors cause illnesses as diverse as diabetes and schizophrenia. Engel uses the fact that, in diabetes, ketoacidosis and hypoglycaemia (physiological conditions sometimes caused by diabetes) may sometimes cause symptoms of altered states of consciousness or behaviour (or, as he terms them, ‘psychiatric manifestations’), to argue that it therefore follows that signs and symptoms associated with diabetes may just be symptoms of ‘psychological distress’ (2005:132), a typical ‘affirming the consequent’ logical fallacy.

    A so-called biopsychosocial approach has consistently ignored the adverse impact of physical illness on mental well-being. This is clear in, for example, in the literature on ME/CFS. A biopsychosocial approach is virtually always, in the medical literature, merely a psychogenic illness for a physical illness.

    Psychogenic explanations for bodily illness are fraught with fallacious reasoning, cause psychogenic dismissal with often catastrophic health effects and, as you say, stigmatization of people as ‘deviant’. The vast majority of the time, as explanations, they are confused between notions of malingering, hypochondria, and the belief in ‘mind over matter’.

    Sadly, the willingness of ‘society’ to allow them to proliferate is related to cultural, quasi-religious reverence towards magical voluntarism and psychological explanations for distress (Smail) which is extended to the workings of the body. It takes a brave woman (or man) to stand up and say psychogenic explanations are unsafe in this day and age!

  43. Henry says:

    Congratulations on an excellent and well written analysis Gill.

    Thoroughly enjoyable despite the grim subject matter.

    However I would just take issue with the implication that these developments were initiated by the current government or are in any respect a reaction to the recent economic crisis and resulting austerity measures.

    In fact this process of ‘facilitating rehabilitation’ of the sick has been ongoing for very many years as thoroughly documented in Professor Malcom Hooper’s document ‘Magical Medicine : How to Make a Disease Disappear’

    This document again discusses the treatment of those with ME/CFS who are all too familiar with the themes and personalities discussed in your review. Perhaps this is due to ME/CFS being portrayed as the MUS ‘par excellence’.

    I fear though that ME patients may have (understandably) been a little myopic in feeling singled out for ‘special treatment’ in the context of a much broader trend that restricts ill health benefits to the tiny minority who can irrefutably prove that they are so seriously disabled that they are incapable of any work no matter how trivial and lowly paid.

  44. Henry says:

    In fact this process of ‘facilitating rehabilitation’ of the sick has been ongoing for very many years as thoroughly documented in Professor Malcom Hooper’s document ‘Magical Medicine : How to Make a Disease Disappear’

    Just to add – this is a hefty document. The sections most relevant to UK government policy and the ‘sub-contractors’ are in Appendices IV and V

  45. Peter Kemp says:

    Superbly written piece that shows that anyone, absolutely anyone, could become a victim of the illness psychologizer’s construct of deserving or undeserving sick.

  46. Fred says:

    Great article, Gill. Well written, clearly presented although, possibly, above the heads and/or beyond the compassion of those whose ideas it challenges.

    A few further thoughts for consideration.

    As you point out, the ‘malingering theory’ is only one explanation of why ill health hasn’t ‘disappeared’ over the decades, despite apparent improvements in health care.

    We are living much longer with ill health. Years ago, many afflictions would have killed us off promptly. Nowadays, precisely because we have a better general standard of living, we survive, our conditions become chronic and we become a greater expense to the state. Perhaps ‘natural selection’ wasn’t so (economically) bad after all.

    Also, our environment and lifestyles have changed significantly. We are exposed to greater pollution (e.g. from manufacturing, transport), industrial chemicals (e.g. pesticides, animal growth hormones), domestic chemicals (e.g. in toiletries, household cleaners), processed food (e.g. with additives, preservatives), synthetic materials (e.g. plastics, nylon), as well as a veritable cornucopia of vaccinations and medications, many of which seem to be prescribed on a ‘suck it and see’ basis.

    We spend extended periods of time at computers, on mobile phones and other gizmos, often with headsets stuffed in our ears. We travel great distances repeatedly and at speed and high altitude. Even our sports and past-times have become more potentially health threatening (e.g. skiing, pot-holing, rock climbing, diving, surfing).

    There are (a lot) more of us on the planet than even 50 years ago. We travel further and more often giving us greater opportunity to spread infectious and contagious disease. Our HVAC (heating ventilation air conditioning) and international mailing systems also provide effective methods for transmitting pathogens.

    At the same time, the medical profession seems ill-equipped to deal with consequent conditions that are newly emerging and/or on the rise. For example, the fields of immune incompetence and chemical or food sensitivity are ones that draw blank looks from most UK GPs and specialists. This, of itself, could be one reason why the psychosocial model has attracted such support: it protects professional pride by providing an ‘answer’ where there is none yet.

    In such a context, the Government/its advisers seem to be using an inappropriate and over simplistic benchmark (i.e. the number of sick people 50+ years ago) against which to measure health ‘progress’. A more insightful start point would be: what illnesses do we have today, which ones are on the increase and how can we address them? Instead, the Government appears to assess sickness purely on the basis of ability to work.

    Under FoI, the DWP has provided a break-down of incapacity benefit (IB) and ESA claimants by type of primary illness for the last ten years. The DWP classifies these illnesses according to block codes in the World Health Organisation’s International Classification of Diseases version 10 (ICD-10) (original, non-updated 1994 version). There are ~1,125 classifications in total vs ~1,500 in the most recent version of ICD-10 (i.e. 30% of the WHO’s most recent classifications do not feature in the DWP’s analysis, including bipolar disorder).

    Of ~2 million IB claimants for year ended August 2010: ~908k (44%) had a primary mental health/behavioural disorder; ~352k (17%) had a primary disease of the musculoskeletal system/connective tissue; and ~237k (11%) had primary ‘symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified’ (i.e. ‘we don’t know what it is’).

    Notwithstanding that the DWP’s ‘automatic process’ for ‘mapping’ ICD codes to claimants may not stand up to rigorous scrutiny *, one would think that the above numbers should engender, at least, some curiosity about, if not a formal investigation into, these large slugs of illness, and from organic and biomedical (as well as ethical and moral) perspectives, not just economic and psychosocial ones.

    * For example, there are an estimated 250k ME patients in the UK but, for year ended August 2010, only ~27k IB/ESA claimants were mapped to a primary classification of ‘other disorders of brain’, a category which includes, but is not exclusive to, ME. Even accounting for ME patients who are pensioners, children and able to work, this still seems too low, particularly given that 25% (~60k) are estimated to be severely affected (i.e. house and/or bedbound).

  47. HS says:

    Thank you Gill for writing this article. I have been waiting for 5 years for someone to research this scandal and document. Please dig further and try to get published in one of the mainstream newspapers. No-one in the general public unless they are ill are aware of this fraud. You are on the verge of exposing a massive scandal. Sadly I think it will take another 20 years or so for all the british public to have woken up to this scandal.

  48. john r says:

    This is a superb article and all genuine progressives need to forward it on: unions, the left, the occupy movement,churches, uk uncut, etc, all would benefit from reading and absorbing this incisive document, along with the Spartacus Report people are now accessing the intellectual tools needed to challenge the neo-liberal welfare reforms(which are of course happening globally) though visible protests are needed as well. Sadly, the anti-welfare reform (or shall we say pro positive reform) movement has been somewhat limited, attempts were made to challenge N/l’s initial W/R’s but sadly at the time issues like ‘antiwar were dominant not helped by far left sects ignoring the issues

    There was also the excellent article by Jonathan Rutherford which details the genesis of NL’s welfare reforms and role of Unum etc in the development of the ‘reforms, though sadly he seems to now support most of them under the Blue Labour flag…

  49. john r says:

    we should also be aware of the involvement of the nominally centre left thinktanks such as the IPPR which provided the intellectual framework, such as it was, for the abolishing of Incapacity Benefit and the introduction of ESA, Kate Stanley of the above was publishing work to promote this as early as 2003, they seem to live in a different world to those at the deep end…

  50. Annie says:

    Thanks Gill for a great analysis of the thinking behind the welfare reforms for the sick and disabled.

    Patrick, I read your comments with great interest. Two things come to mind, you argue that the current system doesn’t work for the sick and that the most deserving need to get support as currently there are those getting support who you believe don’t need it, ie, fraud.

    Well regards fraud, as others have pointed out to you, the DWP’s own statistics say fraud for Disability Living Alliance is 0.5%, so a miniscule amount and fraud for Incapacity Beneft in 2010 (now replaced with the very harsh ESA where 40% are successful on appeals after being refused) was 2.4% (look here at the table, page 12

    As for saying the current system doesn’t work for the sick. The proposed DLA reforms are certainly not going to help the disabled and vulnerable. and the new ESA which replaced incapacity benefit in 2008 has caused much suffering and stress for sick people with frequent assessments and many claimants being wrongly refused and having to go to appeal. THese people are sick and stress makes people who are sick worse. All these reforms for sickness and disability benefits when fraud isn’t even that high.

    The government have issued a draft document for the new proposed PIP which is to replace Disability Living Alliance. In it they give fictional case studies. Case study 7 is of a man who lost a leg in an accident. He finds walking very tiring after 40-50 metres and so has to use a wheelchair if he walks further than this. The new criteria says if anyone walk can walk 50 yards or more they are only entitled to the standard rate mobility component. With the current DLA, this man would be entitled to the high rate. So the state is happy to say that someone who needs to use a wheelchair apart from very small distances is not deemed disabled enough to get full help. I wouldn’t say this is going to help the sick and disabled.

    THe current reforms mean unless someone is severely sick and disabled help is going to be much reduced. Those who are too ill to work (especially those with fluctuating conditions) but not so sick they are confined to bed are going to fall through the net with the current reforms and the system has a good chance of exacerbating their illnesses, preventing further improvement, not to mention people who have already been dealt a bad pack of cards in life who are now going to face futher hardship and isolation.

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