Citation
Perkins, R. and Repper, J. (2015), "Editorial", Mental Health and Social Inclusion, Vol. 19 No. 4. https://doi.org/10.1108/MHSI-08-2015-0036
Publisher
:Emerald Group Publishing Limited
Editorial
Article Type: Editorial From: Mental Health and Social Inclusion, Volume 19, Issue 4.
Extending compulsion: making benefits dependant on accepting treatment
The government has commissioned Professor Dame Carol Black to conduct a review into how best to support benefit claimants with “potentially treatable conditions”, such as obesity or addictions to drugs and alcohol, back into work (Department for Work and Pensions, 2015). The terms of reference for this review include “[…] considering the case for linking benefit entitlements to take up of appropriate treatment or support” (p. 5).
The Prime-Minister explained this approach thus:
Too many people are stuck on sickness benefits because of issues that could be addressed but instead are not. Some have drug or alcohol problems, but refuse treatment. In other cases, people have problems with their weight that could be addressed, but instead a life on benefits rather than work becomes the choice […] It is not fair to ask hardworking taxpayers to fund the benefits of people who refuse to accept the support and treatment that could help them get back to a life of work[1].
This is deeply alarming and nothing less than compulsory treatment by another name. People should have access to treatment and at present there are many who do not […] but is it not unfair, unethical and probably illegal, to compel people to receive treatment under threat that their benefits will be cut or stopped?
The deserving and the undeserving
The suggestion seems to be that obese people, and those with addiction problems, are somehow responsible for their problems and therefore not entitled to tax-payers money unless they accept treatment. This moves away from the fundamental, guiding principle of the NHS, and the welfare state, that it is available to all and that treatment must be based on consent.
Does anyone really “choose” to become obese, or chose to become addicted to drugs or alcohol? The causes of such issues are many and complex and they are frequently a consequence of other challenges. As Sayce (2015)[2] describes:
If, for instance, you experience anxiety due to life events (from abuse to unemployment), drink alcohol to mitigate it, become dependent on alcohol, face social rejection due to your problems, which exacerbates your anxiety then just “treating addiction” is missing the point. A social understanding of both the multiple causes of addiction and the social consequences rejection, unemployment are needed. We need to move from narrow medical models in which a problem is seen as an illness, and the solution as a treatment.
To become obese, or addicted to drugs or alcohol, does not constitute an active “life style choice”.
It is not fair that that there be a different set of requirements, and a differential service, for those who are deemed to have supposedly “chosen” activities that have a negative impact on their health. And it is not all such activities that might be sanctioned in this way. Smoking, drinking, drugs, obesity make popular, headline grabbing targets, etc.:
David Cameron says taxpayers should no longer “fund the benefits” of obese people or drug and alcohol addicts who refuse to accept the treatment that could help them get back into employment (The Telegraph, 13 February 2015)[3].
But what of other “life style choices” that have consequences for health? What about people who “choose” to work long hours? Recent research shows that the consequence of this “choice” is a 33 per cent increased risk of having a stroke (Kivimäki et al., 2015). What of athletes who develop joint problems and injuries as a result of the excessive load on their bodies imposed by their training or mountain climbers who lose digits or limbs as a consequence of frost-bite and other climbing-related injuries? Should their benefits not be stopped unless they desist from their dangerous pursuits? No, it seems that some societal “norms” are more acceptable and deserving than others.
It is worth noting that, by May 2014, only 1,780 of the 2,501,480 people receiving Employment Support Allowance, Incapacity Benefit or Severe Disablement Allowance had “obesity” as their primary disabling condition 0.071 per cent. Although slightly larger, the proportion with addiction problems was also very small: 1.3 per cent had “drug misuse” and 2.2 per cent had “alcohol misuse” as their primary disabling condition. There would not appear to be a “rising tide” either. In May 2010, 0.078 per cent of claimants had obesity as their primary condition, while 1.9 per cent had “drug misuse” and 2.1 per cent had “alcohol misuse”.
Unethical and probably illegal
But what of consent?
Can a person truly be said to be consenting to treatment if they are only doing so under threat of loss of benefits? Simon Wessely, President of the Royal College of Psychiatrists thinks not:
[…] consent to treatment must be free from undue influence, otherwise it is legally meaningless […] treating an unemployed patient for obesity or drug/alcohol problems on the basis of them only undertaking treatment to avoid a review of their benefits could put any professional at serious breach of litigation […] a doctor would be in breach of General Medical Council (GMC) guidance on good medical practice and consent (Wessely and Smith, 2015).
Unless a person lacks mental capacity (and most do not) or is subject to the provisions of the Mental Health Act (which most people with addiction problems and those who are obese are not) then it is legally an assault to medically treat someone without consent:
'Consent' is not consent if made under threat of poverty (Sayce, 2015).
It is also important to note that interventions for both obesity and addictions do not have a particularly good track record.
In relation to drug treatment in England in 2013-2014, figures from Public Health England[4] show that of the 193,198 clients aged 18 or over in contact with treatment services, 181,420 were effectively engaged in treatment for 12 weeks or more (or left before 12 weeks free from dependency). The number completing drug treatment free of dependency was 29,150 (16.1 per cent).
An Editorial (2015) in The Lancet Diabetes & Endocrinology makes it clear that:
[…] diet and life style interventions have restricted, often transient, benefits due to biological adaptations, that act to sustain high bodyweight.
Bariatric surgery may be more effective, indeed NICE guidance concludes that:
The NHS should offer weight loss surgery to thousands more people in order to tackle an epidemic of type 2 diabetes[5].
However, such major surgery also carries with it complications. Not only can infection, blood clots and internal bleeding result from the surgery itself, subsequently gallstones, stomal stenosis, gastric band slippage and food intolerance are not uncommon[6].
Therefore not only would people's “consent” to treatment be dubious, they would be compelled, under threat of loss of benefits, to receive treatment with only a modest success rate or major negative effects. Are outcomes likely to be improved by compulsion?
Probably not. The evidence suggests that, in general, positive incentives encourage positive behaviours and negative ones don't. Far from reducing costs and freeing up resources […] this is much more likely to waste resources by forcing people into treatments that they don't want (Wessely and Smith, 2015).
People who are obese, and those with addiction problems, already experience a great deal of discrimination and exclusion. Suggestions that their benefits be contingent on receipt of treatment, and all the media coverage that this has attracted, are likely to increase the negative attention that people facing such challenges experience. This is likely to have an adverse effect on self-esteem and self-confidence that could easily exacerbate the very problems that it is trying to alleviate.
The thin end of the wedge?
This is not the first time that the idea of making benefits contingent on accepting treatment has raised its head. Almost 20 years ago, a letter from the Royal College of Psychiatrists to the House of Commons Social Security Committee (Thompson, 1996) proposed making psychiatric patients' welfare benefits contingent on their compliance with treatment.
If the principle of making benefits dependent on receipt of treatment is accepted in relation to drug/alcohol problems and obesity who is to say it will not go further? Would it, for example, include people whose obesity was a consequence of treatment for another condition: psychiatric medication, steroids or chemotherapy for example?
Already the scope of the current review by Dame Carol Black has been broadened. When it was announced in February it was limited to obesity now it has been expanded to include drug and alcohol dependency[7]. But the first paragraph of the “call for evidence” makes it clear that the remit could, in fact, be much wider still:
The government has commissioned Professor Dame Carol Black to undertake an independent review into how best to support benefit claimants with potentially treatable conditions, such as obesity or addictions to drugs and alcohol, back into work (Department for Work and Pensions, 2015).
Concerns have already been raised in relation to Cognitive Behaviour Therapy (CBT). At the moment efforts are being made to increase access to CBT for people claiming benefits who have “common” mental health problems. At present this is voluntary, but there are concerns that:
[…] the aim is to make the treatment mandatory refuse and you'll lose your benefits (Marsters, 2014).
But the potential remit is far wider than the mental health arena, where compulsion is already enshrined in the Mental Health Act (Perkins and Repper, 2014).
If it is really about targeting “treatable health conditions” then where is the limit? Indeed are not all health conditions “treatable” to some extent even if that treatment consists of palliative care or pain relief. Indeed, given the plethora of exhortations to all of us to “take responsibility for our own health” (exercise, lose weight, stop smoking, have five portions a day, eat a balanced diet, moderate our alcohol intake, etc.) maybe it goes wider than that:
If it's about people whose choices impact on health conditions/impairments, then what about rock climbers or hang-gliders? Should anyone engaging in risky activities have their benefits stopped? (Sayce, 2015).
To conclude with the words of Wessely and Smith (2015):
Coercing people in this fashion is probably illegal, unethical, impractical and won't save money. As Talleyrand said, “it is worse than a crime, it's a blunder”.
Notes
http://disabilityrightsuk.blogspot.co.uk/2015/08/making-benefits-dependent-on-accepting.html (accessed 24 August 2015).
www.telegraph.co.uk/news/politics/david-cameron/11412218/Obese-people-could-have-benefits-taken-away-if-they-refuse-treatment.html (accessed 24 August 2015).
www.nta.nhs.uk/uploads/drug-treatment-statistical-bulletin-2013-14.pdf (accessed 24 August 2015).
www.nice.org.uk/news/article/offer-weight-loss-surgery-to-diabetics (accessed 24 August 2015).
www.nhs.uk/Conditions/weight-loss-surgery/Pages/risks.aspx (accessed 24 August 2015).
www.theguardian.com/society/2015/jul/29/benefits-drugs-alcohol-obesity-refusing-treatment-review (accessed 24 August 2015).
References
Department for Work and Pensions (2015), “An independent review into the impact on employment outcomes of drug or alcohol addiction, and obesity/call for evidence”, available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/448830/employment-outcomes-drug-alcohol-obesity--independent-review.pdf (accessed 24 August 2015)
Editorial (2015), “Tackling obesity is coercion an option?”, The Lancet Diabetes & Endocrinology, Vol. 3 No. 4, p. 227, available at: www.thelancet.com/journals/landia/article/PIIS2213-8587%2815%2900051-0/fulltext (accessed 24 August 2015)
Kivimäki, M., Jokela, M., Nyberg, S.J., et al. (2015), “Long working hours and risk of coronary heart disease and stroke: a systematic review and meta-analysis of published and unpublished data for 603 838 individuals”, 20 August, available at: http://dx.doi.org/10.1016/S0140-6736(15)60295-1 www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2815%2960295-1.pdf (accessed 24 August 2015)
Marsters, K. (2014), “Linking mental health treatment to job support is a cruel concept”, The Guardian, 6 August, available at: www.theguardian.com/commentisfree/2014/aug/06/mental-health-treatment-job-support-benefits (accessed 24 August 2015)
Perkins, R. and Repper, J. (2014), “Editorial the elephant on the table”, Mental Health and Social Inclusion, Vol. 18 No. 4, pp. 165-8
Sayce, L. (2015), “Making benefits dependent on accepting treatment: why should you care?, available at: http://disabilityrightsuk.blogspot.co.uk/2015/08/making-benefits-dependent-on-accepting.html (accessed 24 August 2015)
Thompson, C. (1996), “Letter from the Royal College of Psychiatrists (ICB 20)”, Session 1996-97, House of Commons Social Security Committee, London
Wessely, S. and Smith, G. (2015), “Linking benefits to treatment is unethical and probably illegal”, The Guardian, 29 July, available at: www.theguardian.com/commentisfree/2015/jul/29/coercing-people-mental-health-problems-work-treatment?CMP=share_btn_tw (accessed 24 August 2015)