Duty, by Dr Avon

One of the responsibilities of doctors (leading to great privilege in the form of good wages and social status) is to act as an informed, accurate and unbiased opinion about people’s access to welfare on the grounds of health problems. Another responsibility of the doctor is to act as an advocate for their patients so that they can access welfare they are entitled to by any reasonable interpretation of the requirements as well as to protect them from any adverse effects of the welfare system that they are vulnerable to. This responsibility can be discharged by communicating with the relevant welfare agencies by various means such as filling out forms, writing letters and direct communications by phone or email. In this blog I tend to use the term “patients” as a generic term used for people consulting a doctor.

Whilst the social model of “disability” is by far the most helpful in order to plan interventions to reduce adverse consequences of mental health problems (my crude understanding of this model is what barriers are there that prevent this person’s desired participation in society including access to their needs for food, shelter and security being met), access to benefits are based on a more medical model of medical condition (identified by diagnosis), associated impairments in functioning and resultant disability (lack of capability or restriction) and social disabling (subsequent disadvantage and lack of fulfilment of social roles such as work or independence without care).

A first point is that the diagnosis is usually insufficient and details need to be given about any resultant impairment. For many diagnostic constructs, the diagnostic criteria are used to identify the best-fitting diagnosis and are not in themselves the whole nature of the condition. To use a general medical example, myocardial infarctions (“heart attacks”) are often identified using a combination of cardiac muscle enzyme results, ECGs, typical descriptions of symptoms and so on but the myocardial infarction itself is a blockage in the blood supply to the heart muscle leading to death of cardiac muscle tissue and resultant complications. It is this blockage and resultant complications that leads to death and impairment in functioning but the diagnostic criteria are used to identify the condition and access to correct treatments and as a first step to other help such as benefits if unable to work afterwards.

Depression is more than just the listing of diagnostic criteria in diagnostic manuals (and in this case the criteria are not as clearly linked to an underlying cause as they are for myocardial infarction). It is this whole nature of depression that is important for the purposes of access to benefits – lethargy, the dread of any change in case it makes things worse, the loss of confidence, the self-doubt, anxiety, avoidance of social contact, poor concentration, thoughts of self-harm etc. The diagnostic construct means the person is more likely to have features associated with that construct that may make them eligible for benefits. It is then up to the doctor to spell out what these features are, what treatment they are receiving, whether they are receiving services such as inpatient or day patient or outpatient, what impairments in functioning result and/or what risks arise to the person or others and what nature of support is needed from others. For example, if someone has agoraphobia they will struggle to leave the house – one consequence is they will find it hard to keep a job. Someone with dementia may wander and get lost so need somebody supervising them. Somebody who is suicidal is a risk of death so will need support and watchful care.

There several papers I use to help me fill out these forms (see references, all open access but all last millennium) but care coordinators such as CPNs and social workers are much more aware of the intricacies and requirements of the system. CAB and welfare rights organisations can provide helpful guides to completing form.

The second point and one frequently made is that the benefits system suits physical health conditions better. It is much harder in mental health to demonstrate that the impairment in functioning is due to the condition – for the myocardial infarction there are tests both associated with diagnosing the condition as well as associated impairments in functioning. In mental health apart from some exemptions such as dementia the demonstration of impairment in functioning is often reliant on the “word” of a mental health professional – it is therefore necessary to fill in the forms requested by benefits agencies so that the doctor’s patient can prove their eligibility. The benefits agencies will weigh up the reports of impairments in functioning, the risks and need for support and care.

The third point is that the benefits system can cause distress to people who are most vulnerable to this problems and increase their mental health problems and risks. Waiting for benefits with no income or savings leads to practical problems as lack of access to food and how to pay the rent multiplied many-fold if the patient has dependents like children. Assessments including reviews of eligibility are major existential threats to many patients on benefits. The lack of tests in mental health mean patients fear they will be disbelieved and the stress caused by these procedures can lead to relapses of mental health conditions and increased risks such as suicide. It is important that mental health services support their patients by completing these forms and if necessary direct contact with benefits agencies – by phone, letter or email – to point out these adverse and counter-productive effects so that patients are protected from these effects.

It is the duty of doctors to help their patients access benefits to which they are eligible, to provide accurate unbiased information as needed to benefits agencies and to help patients by interceding if they are suffering adverse effects from the procedures of the benefits agencies.

References

Disability and Incapacity Benefits – the role that doctors play. Maura Killoughery
https://www.cambridge.org/core/journals/psychiatric-bulletin/article/disability-and-incapacity-benefits/5F3F034CF0D64DC4A6117255701D7465

Incapacity Benefit. Phillip D. Marshall
https://www.cambridge.org/core/journals/psychiatric-bulletin/article/incapacity-benefit/EBD5705BFF05F942B59E69391601B5DA

Mental Health aspects of Incapacity Benefit. Laurence G. Measey
https://www.cambridge.org/core/journals/psychiatric-bulletin/article/mental-health-aspects-of-incapacity-benefit/81D0E6F7D6E4ECAC35E75F26F4ADD248


RITB recommends these essential resources for mental health
professionals:

https://newshoundsnewsround.files.wordpress.com/2017/12/benefit-assessments-e28093-exemption-to-protect-vulnerable-patients.pdf

https://www.shop.cpag.org.uk/big-book-of-benefits-and-mental-health-2017-18

https://www.benefitsandwork.co.uk

https://www.shop.cpag.org.uk/welfare-rights-books

http://pipinfo.net

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A critical theorist and activist collective.