‘I need a report stating exactly what’s wrong with me,’ is her opening statement. It is the beginning of my afternoon surgery and I have seen her plenty of times, but never had the opportunity for a thorough and meaningful encounter. I am aware of the long back story including various mental health diagnoses and encounters with all sorts of state organisations. I am also aware of the various interlinked conditions, ranging from obesity to high blood pressure to interactions between the side-effects of antipsychotic medication, their effects on weight and the risk of developing diabetes. And the aching knees. And the poor sleep. And the precarious financial situation.
I could press a special button and the printer would deliver a piece of paper with the main disease codes including a fairly recent statement about her frailty. But she is only 45! The code has been applied by the invisible hand on the basis of her unscheduled care encounters.
Researcher Clare Bambra writes about welfare administration: ‘It is unclear how all this will play out, but it seems likely that the deserving/undeserving dichotomy may well reinforce and magnify the existing stigma attached to claims that are based on mental illness and may therefore further increase health inequalities. Either way, it will have important implications for the health professionals involved, as the validity of professional medical certification is being questioned by the government, and healthcare workers will become increasingly involved in regulating the poor’ (my emphasis).
‘Why do you need this report?’ ‘I need it for my PIP.’ If I just gave her the generic printout it would be fairly meaningless. If I wrote a detailed factual report stating her situation, her diagnostic labels, her impairments, her activity limitations and her participation restrictions it would take me about 45 minutes (of my time, unpaid, whereas medico-legal reports by insurance companies are paid for by the companies) and there would be a high likelihood that it would contain inaccuracies. I hear from disability benefit advisers that most of the reports by GPs are inadequate (to say the least).
This is a problem. On the one hand, such reports can have a huge impact and may be influential in processes of social administration and clarify the medical situation of the claimant.
On the other hand, they require a great deal of knowledge about the patient/claimant, about processes of social administration, about cut-offs in assessments of physical and social functioning and the intricacies of welfare administration. Very few doctors know these things.
One problem is that the process is geared towards an essentialist formulation (disease), so relational formulations (an analysis of her impairments in the context of her life history and lifeworld) disappear in the assessment grid.
If people present with sleeplessness and low mood I have to ask what they are thinking about when they are not sleeping. If I am curious and interested I may hear about the debt. Many people are too ashamed to volunteer information about their financial situation. Being poor has become a shameful state.
‘How much money would you need, if I could prescribe money instead of antidepressants and pain killers?’ ‘Three thousand pounds, I am in arrears with my rent and may face eviction.’ And I am reaching for the next foodbank voucher. There are boxes to tick: ‘Benefit changes’, ‘Benefit delays’.
This is serious and important. Every doctor WOULD see it as an emergency if their credit card got swallowed up in the hole in the wall and the fridge was empty.
Financial stability and food security is at the foundation of Maslow’s hierarchy of needs. They are the priority. GPs deal with these matters on a daily basis, particularly if they practise at the Deep End, in poor areas. The Faculty of Public Health argues for better mental health for all and relates the mental health of the population to politics and policy: job insecurity leads to housing insecurity – this is a fundamental stressor and exacerbates mental health problems. As an inner city GP I am faced with the physiological consequences, but my job does not end here. It is about addressing the causes of these ‘idioms of distress’. And this must be more than suggesting mindfulness…..
In my personal practice I decided to give more attention to these reports as important influences in processes of social administration. They highlight important intersections between illness (what the patient feels), disease (the measurable examination and investigation findings) and sickness (societal response to health-related changes in social participation). If such a report is done properly in collaboration with the patient it can be an important part of the therapeutic partnership. But it means ‘going the extra mile’ in an already overstretched working environment.