Few politicians in the UK would dare to argue publicly against the principle that those too ill to work deserve help from the the State. Nevertheless, in recent years, politicians have struck a chord with the public by highlighting the disincentives to work that are inherent in the UK disability benefits system. The main disincentive is financial, with the state providing more money to those who can’t work because they’re ill than to those for whom no job is available. This, coupled with the fact that for some people paid work still brings them within the threshold for receiving income support, means that for some people it pays to be too sick too work.

All matters far from my holidaying mind until I came across an article in the local newspaper, here in Oregon in the USA, entitled “Getting disability payments can be a fight to the death”.

http://www.oregonlive.com/news/oregonian/index.ssf?/base/news/1217564703119820.xml&col

This article, the latest in a series run by this paper and others in the USA, seeks to highlight the plight of those subject to a system that is both inefficient and determined not to be misused. The result is that many people who are genuinely unable to work, people who have contributed to a compulsory government-run insurance scheme to protect US citizens against just such an eventuality, can spend years in their attempt to receive their due.

Having read the stories of some of these individuals in The Oregonian, I subsequently became increasingly aware of the television ads that make up maybe 1 in 40 of those on the national channels I watch. Advertisements by lawyers (or advocates as they’re called in the US) who will, for a price, fight on your behalf for disability benefits. The existence and tone of these ads seems to imply several things: that getting a claim for disability payments approved will be a long and adversarial fight; that to win that fight you need to have legal skills; and that to succed will require the sort of energy, stamina and determination to win associated with lawyers hungry for a fee.

Maybe those behind the ads are right. If the facts and figures in The Oregonian article are to be believed then claiming disability benefits in the US may not be something ill people would be advised to attempt on their own. Reading this and other articles, and watching the TV ads, I was struck by the marked absence of any medical advocacy. The only role of doctors in these stories seemed to be as diagnosticians and as occupational health physicians acting on behalf of the government. One of the roles of the former was to decide whether their patients were too ill to work; the role of the latter was to determine whether these assessments about claimants were true, false, or only true for certain jobs. Problems with the system appear to be two-fold: first the long delay between claims and initial decisions and second the litigious nature of the appeals process, with one set of medical experts pitted against another.

My American husband tells me that, historically, the disability payments system has been one of the most abused of all givernment funded benefits. Similar abuses, we are told, occur in the UK equivalent. Hence the recent interest from both major UK political parties in revamping the system by removing incentives not to work and providing help for those who are or have been unwell to get back to work.

As it happens, I work in an area where relatively few people are on long term disability payments. Where I work the challenge is to persuade people to take a few days off work when they’re sick, not getting them to work. Which doesn’t mean I don’t have patients who could work but don’t; people who after years on relatively easily accessed benefits have lost all confidence in their own ability to hold down a job; people whom I feel ill-equipped to help.

So I welcome the idea of helping people get back to work if they can. Because even if it isn’t what they want it may be what they need. And I’ll be relieved when I’m not the person who (effectively) decides- through the certificate I sign stating whether an individual is fit or not to work- whether access to benefits will be forthcoming. I could claim this was because of my all too real ignorance of occupational health issues but it’s not really that. The real reason I don’t like being the one make this decision is because all too often it places me in an extremely uncomfortable position that seems to have little or nothing to do with anything I learned in medical school.

For many of my patients who can’t work there is no doubt in my mind: they can’t work, clearly. For others however things are not so clear cut. Whilst they tell me they can’t work I know many others, in far worse physical or mental health who do just that. Day after day, in pain, anxious, but determined and driven to work by a mixture of personality, pride and determination.

So when I’m asked to judge whether someone is fit to work which standard do I apply? And is that standard something that can be fixed or determined or is it instead something that is created and chosen by different societies, at different times, and with different economic and social imperatives? And if I choose to apply different standards, to say those living in areas where this is little or no work and where working doesn’t pay, am I being a good advocate or just helping to entrench a way of life that leaves those leading it without ambition or hope?

Big questions. The sort, thankfully, we pay politicians to answer. Except that the place UK politicians are looking for answers is the US system and now, after what I’ve read and seen of that system, that makes me uncomfortable. Because whilst I’m as impressed as the next person by the way in which some programmnes in the US have managed to help people off of disability benefits and back into work, I’m concerned that UK policymakers are underestimating the bureacratic nature of the system they wish to emulate and overestimating their own ability to create a system that works better than the flawed one we currently have.

In the end, if a society wants, collectively, to protect its vulnerable members it needs to find a way that discourages abuse without punishing the weak. If that society values work then the system it chooses needs to embue its members with that value, through example as well as incentives. What it shouldn’t do is tolerate a system that is so iniquous that the first thing a person too ill work would be advised to do is to visit their lawyer rather than their doctor.