“Incapacitated” on Radio 4

November 10th, 2008 by Ben Goldacre in not bad science, onanism, podcast | 33 Comments »

So I’ve got a documentary on Radio 4 at 8pm this evening on incapacity benefit, and it’s a bit of a veer from the norm, because it’s a subject where I’m not entirely sure what I think.

Here’s why I care. I once sat drinking with a group of medics, arguing over what would be the single contemporary medical activity that future generations would look back on with horror, and think, “what, on earth, were you playing at?” Would it be another thalidomide, or perhaps a social issue that doctors blindly and obediently waded in on, like when we unhelpfully tried to electrocute gay people straight. The answer we came up with was “nurse-led prescribing”.

Only kidding (I quite like nurse prescribing).

But weirdly, a leading suggestion was incapacity benefit. I don’t know if it’s true that it is the greatest harm we do – I’m pretty sure it’s not – but the whole area is certainly a source of some anxiety and concern for doctors, for a lot of complicated reasons.

Some of us feel that as a profession we have collectively participated in medicalising a social problem; that it’s horrible to be anything approaching a gatekeeper to benefits; and that sometimes, although time off work can be valuable and necessary, it might also, sometimes, be harmful. It’s a chilling thought – but a common phenomenon in medicine – that when you think you are doing good, you are actually doing some harm. This will not be true in all cases, and people on IB are a hugely diverse group, but like with drug side effects, it may be true of some, and it is certainly worth thinking about.

There are 2.6 million people on incapacity benefit today, after all, the largest single group of workless people, and every practical aspect of their lives, their housing, their income, their social role, is founded in an ongoing belief in themselves as incapable people, sanctioned by doctors. We haven’t really researched what the consequences of that will be.

This is a contentious area, and although I don’t think we say anything very provocative, we will receive, undoubtedly, a deluge of angry complaints from people who accuse us of saying things we haven’t said, or think we are challenging their view of their own illness, which we’re plainly not. To be honest, our greatest crime, in what I suspect is not my most stimulating 27 minutes on radio, is that we don’t really say very much at all.

Anyway, here’s a link, and I hope you enjoy it.


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33 Responses

  1. Redski said,

    November 10, 2008 at 6:48 pm

    I have some sympathy with Another George’s point, especially at the point where the job market is shrinking. On the other hand, I’m not especially happy about the creation of thousands (hundreds of thousands?) of people on incapacity benefit who are receiving extra money while not looking for work that they might be capable of doing – and which might help them break out of whatever cycle they are in. Don’t get me wrong, I’m not a rabid rightwinger. Just a taxpayer: I realise very well that there are people on incapacity benefit who are unable to work. I would like to help them more. I would like to give them higher benefits. I also know there are some (numbers? I couldn’t begin to guess) for whom incapacity benefit is a benefit trap – it’s not worthwhile working when the marginal income is so low when incapacity benefit is taken away. So they don’t even look for work
    However, on Dr Ben’s point, I can understand why doctors are uncomfortable about being the gatekeepers for incap benefit. Teachers feel much the same way about having to adminster the EMA (educational maintenance allowance) for teenagers. It costs the taxpayer much less than incap benefit but it’s another piece of social engineering which another profession has to administer on behalf of the government.

  2. MT said,

    November 10, 2008 at 7:27 pm

    It’s a terrible conundrum. When the welfare state was set up, I don’t think they could have imagined the future stresses on it’s resources.

    I work regularly with disabled people, and many are highly politicised about this issue. There is also a furious debate between the ‘medical’ model of disablity and the ‘social’ model of disablity, the latter qualifying anyone who feels disabled by social mores to claim status as disabled – something that’s been parodied on video here www.youtube.com/watch?v=4CTgW0D5YxA

    There is no easy answer to this and it certainly won’t do well getting the Jeremy Vine/false dichotomy treatment.

    I’ll listen to this tonight. It would be interesting to know what the stats on this are with regard to recipients and their subsequent catagorisation.

    Anyway, I have a babies nappy to change…

  3. davemack said,

    November 10, 2008 at 7:42 pm

    I’m hoping to listen to the programme later this evening. One concern I have, as someone who has been signed off for several years on mental health grounds, is that — despite mental health supposedly being an NHS priority, alongside cancer and cardiac care — the medical resources are not available to mental health patients with ‘chronic’ conditions (and yes, this means even the much-vaunted short courses of cognitive behavioural therapy favoured by NICE). If cancer or cardiac patients were treated as shabbily and — dare I say it — negligently, society would be outraged. Lest that last comment be taken as a criticism of the medical profession, I’d have to comment that my ‘beef’ is that in my borough mental health services have in real terms been reduced and the burden falls back on overstretched GPs to manage me, and a lot of other similar people, who should be receiving specialist medical care.

  4. PhilEdwards said,

    November 10, 2008 at 8:08 pm

    Medicalisation is a bugger. When I was a teenager, an acquaintance of mine had an episode of religious mania – nothing especially loopy, he just had a sudden realisation that EVERYONE needed to hear the good news, and they needed to hear it FROM HIM and RIGHT NOW! He was sectioned for a while, simmered down and was sent back home on a maintenance dose of something or other (the last time I saw him I was actually working as a psychiatric nurse, so I would have known what it was if I’d asked, but frankly I didn’t want to). Anyway, when I saw him he was perfectly happy with his lot – the story as far as he was concerned was that his brain suffered from a chemical imbalance* which was being rectified by the medication, but that he couldn’t afford to risk getting a job or going to college, bit of a shame but there you go.

    *I think he got this from a friend’s father, who was manic-depressive and on huge amounts of lithium.

  5. John Smith said,

    November 10, 2008 at 8:34 pm

    What an intriguing picture: Three gods sitting on Olympus, wondering how the mortals will record their actions in 100s of years time…

    Seriously, Ben. I’m starting to enjoy your columns not so much because of what they discuss, but because of what they say about a doctor’s attitude to life, the universe and everything. What’s it like up there?

    Doctors don’t sign people off work. The welfare state does that. Doctors just sign sick notes. You’re a cog in the machine. You ain’t the machine.

    Doctors can no more take responsibility for people being on the sick than the girl behind the counter at the fish and chip shop can be blamed for her customers being a bit tubby.

    You also make a huge assumption: that working is what gives people value. If people don’t work then they’re diminished. Hmmm…. Debatable.

    People don’t have a requirement to work. They have a requirement to make a living. One usually leads to the other, but not always.

    The benefits system is just that — a system. And, as a doctor, you’ll know that this system can be gamed. Really quite heavily gamed, with some stunning skill at times. But so what? People are just making a living. They’re just not making a living by working.

    Give people a system, and they will make use of it. Don’t then blame them for using it.

    And don’t blame yourself for being a part of the system (or, actually, in your particular case, don’t take responsibility for the entire system).

  6. MT said,

    November 10, 2008 at 9:54 pm

    Has anyone come across something called the Pareto Optimum? Robert Wright describes in in one of the first endnotes of Zero Sum. Might be an interesting prism to view this by – (not saying me as the complexities of it make me go cross eyed with ignorance)

  7. clobbered said,

    November 10, 2008 at 11:29 pm

    As to “the single contemporary medical activity that future generations would look back on with horror”, I am putting my money on bariatric surgery.

  8. brainduck said,

    November 11, 2008 at 12:23 am

    BBC Iplayer streaming is too choppy to listen to on a crap connection – any chance of an MP3 to download please?

  9. mjs said,

    November 11, 2008 at 1:06 am

    incapacity benefit? the unexpected horror? i see the argument. the best part is that it’s a subtle and tricky thing to consider from a practitioner’s point of view.

    but honestly, i would have expected Botox to be the winner.

  10. j said,

    November 11, 2008 at 2:37 am

    There’s no transcript?

  11. csrster said,

    November 11, 2008 at 8:56 am

    brainduck, here’s how you do it:

    i) delete windows
    ii) install linux
    iii) download the program with
    mplayer -bandwidth 9000000 -dumpstream -dumpfile ben.ra rmv8.bbc.net.uk:554/radio4/2000_mon.ra
    iv) encode it to mp3 with
    ffmpeg -ab 96000 -i ben.ra ben.mp3

  12. Tristan said,

    November 11, 2008 at 10:16 am

    RS: That’s an impressive blog post. I’ll forward it to my partner who works for a mental healtch charity who have major concerns about the way the new system coming in will affect their service users. As you’ve mentioned, the recurrent nature of some severe mental illnesses makes it difficult to assess whether someone is fit to work or not.

    Ben, that was an interesting programme.

  13. jb said,

    November 11, 2008 at 10:38 am

    A downloadable MP3 version can be found at…

    26.6MB 29:00min 128K MP3

    Ben – Feel free to copy to badscience.net for posterity.

  14. Tristan said,

    November 11, 2008 at 11:52 am

    RS – Your blog post seems to have disappeared! Any possiblity of putting it back up?

  15. The Goldfish said,

    November 11, 2008 at 12:03 pm

    Bless you Ben, none of this is your doing.

    My GP knows my diagnosis, those symptoms which have been worth mentioning of late, the hospital referrals and the drugs I take. She doesn’t know how many steps I can manage without severe pain, how many hours I sleep or any detail about what I spend my day doing. It would require a pretty tedious charade to defraud the system, but every benefit claim relies almost entirely on the evidence (and thus the perception) of the claimant.

    My GP merely confirms that I look sick (i.e I report this group of symptoms, I produce bright green blood etc.). Even when I see a DWP doctor, they can’t do much more than confirm that there’s no obvious physical evidence that I’m either faking or exaggerating my degree of impairment. In any case, it is not a medically qualified person who has the final say in the matter.

    As for claimants considering ourselves fundamentally incapable and um, “festering” as you put it, I blogged for BBC Ouch! on that one here: www.bbc.co.uk/blogs/ouch/2007/07/not_working_not_whiling.html

    By far the greatest problem – both in terms of numbers on IB and the social and psychological effects of being on this benefit – is inflexibility. Our attitudes towards work in this country are inflexible in a way that disadvantages many disabled people. But the benefits system itself is set up in such a way that one is either is found able to work or else it is very difficult to do anything, to experiment with what one might be able to do, or if one has no hope of anything like full time work, to do little bits and pieces of renumerative work without creating a horrendous paper-trail and all manner of hassle from the DWP.

    Doctors may have a role in this, but the worst of it lies in attitudes and systems. Your conscience should be quite clear. 🙂

  16. RS said,

    November 11, 2008 at 12:09 pm

    Tristan, temporary glitch.

  17. briantist said,

    November 11, 2008 at 12:31 pm

    Hi Ben,

    Loved the programme, listened to it last night on the iPlayer.

    You got a bloody good admission out of Anne Widdecome, which was rather brilliant of you.

    For your further delication and delight, have you seen this?


    “During the programme Health is Wealth, a homeopathic practitioner, Dr Professor Mohammed Jamil Jilu (“Dr Jamil”), was allowed to make unsubstantiated and potentially dangerous claims regarding the ability of his homeopathic treatments to cure cancer and other serious illnesses, such as diabetes and hepatitis. This could have resulted in viewers with treatable serious medical problems choosing to dispense with orthodox medical treatment in favour of Dr Jamil’s treatments. This risked serious harm to viewers (breach of Rule 2.1);” etc

  18. mdimmick said,

    November 11, 2008 at 2:18 pm

    A lot of people who criticise benefits are unaware of how small they actually are.

    Long-term incapacity benefit is £84.50 per week – annualised this is £4,394 per year, well below the standard income tax allowance even before it was changed to compensate for the loss of the 10p tax band.

    Since they are on a benefit, they can claim Housing and Council Tax Benefit. If with a private landlord, they can get a Local Housing Allowance rather than Housing Benefit. The LHA is basically up to the median rent for the area, for the size of property that you’re permitted to claim for (one bedroom per adult couple plus one bedroom per child over sixteen, one per two children under 16 of the same gender, and one per two children under 10 regardless of gender). You can keep up to £15/week of any excess (i.e. if the property you’re renting costs less than the median, you keep the difference up to £15).

    Still, you can get Housing and Council Tax Benefits if you’re on a low wage with Income Support, or with Jobseeker’s Allowance, so this isn’t really a difference. IB rates are slightly higher than JSA, so you could argue that there’s a slightly higher incentive to claim IB, but it amounts to less than £25 per week if getting the long-term IB rate (under £5/week for short-term IB).

    There just seems to be the perception that benefits are an easy life, when they really aren’t. A 40 hour/week job at minimum wage would pay £229 per week, nearly three times IB. If there’s a problem with the benefits system, it’s that it’s too complex, leading to people claiming the wrong sort of benefits, or not everything that they could claim.

  19. brainduck said,

    November 11, 2008 at 3:02 pm

    Thanks muchly for the MP3.

  20. EnglishInBaltimore said,

    November 11, 2008 at 6:19 pm

    There was something about this in the FT a while back, some long feature article about the interplay of societal change, expectations about work and incapacity benefit.
    It’s a much much bigger problem than just doctors though. Indeed, as I recall, isn’t the final assessment of Incapacity Benefit out of the hands of doctors and done by some external contractor (yay privatization)?
    Part of the problem is creating rigid categories for problems that are complex, dynamic and fluid. I mean, what kind of disability do you have? How does it affect your ability to work? What kind of work? To what degree? How long? Will it get better? Can the right kind of work help it get better? Does that kind of work exist in the area where you live? Who should be responsible for deciding how you live your life, find meaning, find purpose?

  21. superburger said,

    November 11, 2008 at 6:54 pm

    “A 40 hour/week job at minimum wage would pay £229 per week, nearly three times IB.”

    Yes but being on IB, IS or JSA is a gateway to a lot of other things – free prescriptions, baby formula, school meals,school uniforms, reduced travel costs, etc.

    And every child born is an increase in benefit payments – and from a financial perspective you are better living as a single parent than with a partner.

    Which isn’t to say it’s great being on benefits…

    BUT. 40 hours a week at £5.73 an hours is £229 a week which is £192 take home pay (www.thesalarycalculator.co.uk/salary.php)

    So out of £192, you’ve got all the additional costs of work (travel, possibly clothing) and you have to pay rent, council tax etc….

  22. Owweeee said,

    November 11, 2008 at 8:08 pm

    As somebody on Incapacity Benefit, on of the biggest hurdles to getting better I have found is dealing with the Job Centre. I spend what feels like my entire time telling them that I am mentally ill and every time I do it gets more and more re-enforced in my mind that I am ill, and I can’t spend that time sorting my self out to get better.

    I should point out that I have suffered on and off with depression for that last 5 years and have only spent the last 7 of those on IB.

  23. marcdraco said,

    November 11, 2008 at 8:50 pm

    Owweeee. Try strenuous exercise (strenuous for you) building up from a few minutes per day to 30 minutes 2-4 times per week. I’ve rattled with pills and blood-pumping exercise is the only remedy that actually seems to work (aside from the placebo).

    My attitude hasn’t changed a lot but I just find the depression eases and that makes it easier to cope. (Problem is, you have to keep doing it or the depression comes back.)

  24. John2002 said,

    November 12, 2008 at 8:37 am

    The comments on here that suggest that choosing a life on benefits is a valid decision are a bit sad. We all know that the safety net is there to help people who need help, but making a decision to choose to live off it, rather than to use it when there is no other choice s no more moral than choosing to go shoplifting to save money from the weekly bills.

    The comment that it is a good idea to have people on IB because there is unemployment makes no sense at all. To get the economy in recovery as quickly as possible, we need to get the best people doing each job. Implying that a good reaction to unemployment is to take a group of people out of the working population is crazy. There is no fixed “pot” of jobs, and even if there were, unemployment is still extremely low in the UK.

  25. tjb said,

    November 12, 2008 at 1:07 pm

    Nuts Anyway, the trap is that if I get a part-time job above that IB limit, and then fall too ill to stay in it, I won’t have paid enough NI contributions to go back on any benefits. I shall have no income at all. So even if I think I may be fit enought to work 18 hours (which I don’t), I cannot afford to apply for that job.

    In general, as an IB claimant you would be able to work for up to two years (actually 104 weeks) and return to benefit on the same terms as when you left it if you needed to. You wouldn’t need to re-satisfy the contribution condition. This comes under the so-called welfare to work provisions. But do get independent advice first if you do find an opportunity to start work.

  26. T said,

    November 12, 2008 at 6:08 pm

    My ex brother in law has lost his buisness and health due to the fact he is an alcoholic, who also smokes, in vast amounts….my sister had to leave him in a hurry as basically he would have killed her due to his violent drunken escapades. Before he lost his business he was meant to be paying child support, he didn’t pay up.

    He is now enjoying these extra benefits as he can no longer work.

    ( he has a girl friend who supplies him with extra booze so this supplements his income)

    I know alcholism is an illness but I just dont have any sympathy for this man, I really dont see why he is given extra benefits.

    My sister works her butt off in a low paid job, she is totally depressed and Im really worried for her. She gets no extra help. I’d rather my sister and her daughter got this extra money, than her ex.

  27. SteveNaive said,

    November 13, 2008 at 10:33 am

    I have a neighbour who has been signed off work for 10 years because of alcoholism and other minor psychological disorders. I help him out and listen to him and his worries. The bottom line is that over those 10 years he has become increasingly paranoid and agarophobic. Paying him to sit at home has not only cost the taxpayer money, it has also made him sicker and even less capable of returning to work. He is a skilled builder and fully capable of contributing to society. If he took a part-time job at this stage he would be worse off financially. The system sucks – it’s not the docs fault.

  28. nerd said,

    November 16, 2008 at 7:42 am

    Ah, this is a tricky subject and I can see where some of you are coming from, but I also feel that many of you lack the experience of actually being on benefits.
    I had always worked, I held part time jobs since 14, worked 30 hours/week when sitting my A levels and got a job once I left college. I even bought my first house when I was 18.
    For a while everything went well and I worked on short term contracts with various charities on different projects. Until I got ill. Suddenly all the short contracts weren’t such a good idea as I had no entitlement to work sick pay. After a pretty long period of being admitted to hospital every few weeks, having no income whatsoever and nearly losing my home as a consequence I claimed incapacity benefit (but this could only be claimed after 6 months out of work sick) My income had gone from nearly £300/week pre tax to about that amount per month which was a huge struggle. My employers at the time decided to discontinue my employment with them and suddenly I had no job to go back to. I was in no position to return to work at that time and spent the next 2 years recuperating whilst trying to live on IB. My illness has left me with ongoing problems and this has made it very hard for me to find work. Even when I have applied for things I generally do not even reach interview. The only jobs that the job centre came up with were very low grade menial work and nothing even similar to the work I had done since 18.
    After 2 years of living on IB and doing some “permitted work” I decided to try and return to full time employment. That was all fine for just under 20 months, 14 months on one contract followed by 5 and a half elsewhere, when suddenly my illness recurred and I was once again having my contract “discontinued” while under probation. So I find myself now back on benefits. I have suffered a great deal with my health and for the time being I am greatful for the chance to try and recover until I can return to work in the future. I have expereinced a great deal of prejudice from other people because of my health problems, from work place discrimination through to comments from people who assume I am stupid or lazy or mentally deficient. I am none of these things but I am not prepared to further worsen my health by taking on work that I am not yet ready for.
    Trying to get by on the money I receive from IB is not at all easy. For example this winter I have the choice of either eating well or turning on my heating.
    I also wonder what some of the people on here who seem to be against IB make of my fathers current situation – after leaving school at 16 and going straight into to work in order to help his mother and younger siblings, and working solidly right the way through to 50, he is suddenly trying to get by on IB after being diagnosed with terminal cancer. Not only facing the difficulty of dealing with that news he has faced the indignity of a DWP “workfocus interview” in order to see if he could be doing any work at all. He was told that if he did not attend these interviews then he would lose his benefits. He has been given just months to live, after contributing to the system all his life.
    While I can see that there are some who abuse this system please do not think that everyone claiming IB is workshy, lazy or fraudulant.
    Incidentally as a homeowner I am not entitled to some of the other benfits people have mentioned here, such as housing benefit or free prescriptions. How ironic that those who are off work through ill health do not automatically qualify for free prescriptions but those living on IS who choose not to work do.

  29. Simon27 said,

    November 20, 2008 at 9:04 pm

    As Ben says this is a complex problem and one that at least is now being tackled. The new Employment and Support Allowance is designed to help those who have basically been abandoned by sucessive governments. It is true that in the past people were shunted onto IB to keep the unemployment figures down, once they were on IB there was no need for any contact with a government agency. Thus even if the condition was self limiting you could remain on it for life. There is some evidence that work is better for you. People on IB die younger, are more socially isolated and of course poorer. There is an economic argument as well. The contraction of the labour market is only temporary, demographic changes mean we are becoming an ageing society, we will need all the labour we can get. I recommend DAme Carol Black’s report on the health of tthe nation which at least has some evidence base, if challengeable.

  30. Tim said,

    November 25, 2008 at 1:30 am

    Balls. Missed it. That wasn’t up for long. Glad I pay a license fee…

  31. jb said,

    November 29, 2008 at 11:09 am

    Tim, it’s still available to download (comment #19) from…


  32. Mma Rodj said,

    June 16, 2010 at 12:52 pm

    People on sickness benefits “die younger… and of course poorer”. No shit, sherlock!
    And for your next trick, a scheme where people so sick they can’t work get to live longer than the general population, and be richer too.


  33. Mma Rodj said,

    June 16, 2010 at 1:06 pm

    Since I’m here…
    “once they were on IB there was no need for any contact with a government agency.”
    Also cobblers. People were re-assessed by DWP doctors (these days, ATOL nurses) at appropriate intervals.

    And there was no “abandonment”. The Pathways to Work variably helpful work-preparation scheme has existed for a while – but now it’s compulsory and Nerd’s terminally ill father is summonsed to Work-Focussed Interviews to assess him for it.

    You are David Freud, and I claim my £10 pounds.