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Gold, incentives and meh

Should patients who refuse treatment have their benefits cut?

Dr Neman Khan argues that benefits should be dependent on patients accepting help but Dr Zoe Norris says that addictions can’t be solved by cuts

YES

I recently wrote the death certificate for one of my patients, an alcoholic, who went from working and drinking hard, to drinking too much and losing his job.  I signed him off for rehabilitation, but he soon seemed to realise that he could stay off work with benefits essentially paying him to remain semi-comatose at tax payers’ expense, drinking all day.

I support and encourage any addict who wants to turn their life around - as long as they are engaging with drug and alcohol services, I have no problem signing them off to allow them to focus fully on their recovery and return towards being productive members of society.

But I firmly believe that benefits should be dependent on the patient engaging with rehabilitation services. I don’t usually agree with Conservative health policy, but the party seem to share this principle. Their manifesto promises to review whether patients with ‘long-term, yet treatable conditions’, including drug and alcohol addiction or obesity could have their benefits reduced if they refuse recommended treatment.’

Giving benefits to those not seeking help may be enabling their addictions.  After all, I have never met a patient who can buy drugs or alcohol without money. Drug addicts and alcoholics get £435m in sickness benefit, but surely some of that would be better spent on improved rehabilitation facilities? The Government should provide homeless shelters and meals to those not getting benefits, so they can’t fund their habits but won’t be forced further into poverty.

Dealing specifically with the issue of obesity, the cost to the UK economy of overweight and obesity was estimated at £15.8 billion per year in 2007, including £4.2 billion in costs to the NHS. Patients shouldn’t be signed off for obesity unless they are morbidly obese and need time for recovery from bariatric surgery.

But prior to surgery being suggested, any reason to get up and out of the house can only be helpful, with work-related activities helping the patient to expend their energy in a positive way. Paying benefits to those at risk could be dependent on them spending time in the gym on a daily basis if they’re not in work.

To those concerned that the proposals would increase GPs’ workload by making GPs into inspectors, I’d say that monitoring can be done by the rehabilitation facility or the gym in the form of electronic registers. The Department for Work and Pensions can deal with the financial side if patients don’t attend.  All the GP would do is decide whether the patient is fit for work, as they do now.

If my patient had been forced to return to work rather than given money to fund his lifestyle choice, I can’t help thinking that perhaps he would still be alive now.

Dr Neman Khan is a GP in Woking, Surrey

 

NO

The Conservative Party’s proposals fail to acknowledge that working with addictions is far too complex to be solved by a simple carrot and stick policy.

Working with patients with addiction problems – including that to food – is a complex challenge. It requires time to build trust with these patients, and understand the often deep-rooted and complex reasons for their problems.

If the threat of a financial penalty was all it took to change patient’s behaviour, we would have had much more success with conventional methods by now. We constantly advise patients about their lifestyle, and how it impacts on their health. This makes surprisingly little difference to health outcomes, and most of us can count on one hand the patients who truly take our advice on board and come back six months later having lost five stone, stopped smoking and taken up regular exercise.

Those patients with addictions to prescription medicines, drugs or alcohol are even more complex. Their histories started in childhood, and we see a tiny part of that when they present to us. To assume that such complex patients can be ‘solved’ by threatening penalties does a disservice to the patients who can see no way out of the vicious cycle of addiction, poverty, social inequality and an endless reliance on the NHS in all its forms.

It takes time, a rock solid doctor-patient relationship, and a whole raft of factors that are entirely outside our control as doctors for these patients to both engage and improve.

Dedicated services often fail and patients are charged with the task of having to change their whole lives. These problems that could – at a stretch – have been considered lifestyle choices at the start, are multi-factorial and need all our skills to try and help.

What’s more, this proposals would undoubtedly affect the doctor-patient relationship and increase our workload. It’s not clear whether it would be our job to check-up on patients who say they missed a treatment appointment because of illness or family issues. Or whether we’ll be encouraged to inform on patients on a special hotline.

The idea is also fallible, because there is bound to be some level of exemption for certain categories and many of this group are familiar with the system and how it works, and know which boxes to tick.

When the worst happens, and these individuals find their benefits cut, I wonder where they will end up. Which professionals they will turn to that are free and easy to access. It doesn’t take a genius to realise the proposals would put even greater pressure on primary care, all for a few votes.

Dr Zoe Norris is a GP in Hull

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Readers' comments (16)

  • If patients with addictions or who are obese and refuse treatment end up having their benefits cut -

    then all those patients who are not on benefits and who are not addicts but are obese, who do not control their diets (if they are diabetics), do not take medications regularly (no non-compliance) , who do not attend appointments with GPs and Hospitals, who do not exercise and rely on medical intervention for everything - they should be made to pay through their nose and should not have any free NHS treatment : because these please who considers themselves to be the good ones and wasting more of the resources than anyone else.

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  • I absolutely agree with the concept of UBI. If this is set at the right level then no-one need starve and the onus is firmly on the individual to decide to live at this basic level or to take whatever steps are necessary and possible to improve their lot. I appreciate of course that even this solution will not solve the problem completely and brings other difficulties and problems with it. However we will not solve the problems by refusing the basic human right to be treated whatever the reason for the medical problem. To do so would be immoral and uncivilised.

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  • 1.13 - absolutely bang on.

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  • I am not for cutting benefits for those with addictions but unless they are engaging with treatment I see no reason to sign them off work. Put it this way, you would not give a suicidal patient the paracetamol to top themselves with, so why should an addict be funded to engage in the addiction? Of course things would be easier if the same government that proposed this acted on a fat tax and took more action on cheap alcohol. And things would be even better if narcotics were legalised & REGULATED as the war on these drugs that ruin so many lives is being lost. So, yes I am in favour of addicts who fail to engage not being signed off due to medical reasons, but I think it is far more important to act on alcohol pricing and bringing in a fat tax to aid healthy eating.

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  • interesting points of view, ... the main drivers for these types of patients as with many others are mostly social and economic... and until we get to grips with these issues the addictions and waistlines will continue to increase. While some continue to manage the addicts mostly with the ghettoisation of areas known for their drugs (?institutionally sustained & controlled so that the drug problem is contained in some areas) and dish out the kebab shop licenses to some and not others we as GPs will continue to be the tiny end pieces in a much bigger societal game.

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  • Always a danger that this sort of debate invites the tree hugging lefties - please don't seem so 'shocked' all the time

    I have always adopted the principle that if I am signing off someone from work they must be engaging with rehabilitation

    I they aren't, I don't - that's the deal

    As GPs we cannot become seduced by feckless scroungers, it is no one's interests not least the scroungers themselves

    Where possible, work is good for you

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