The Conservative Party’s 2015 election manifesto contains an extraordinarily retrograde assault on the rights of people with mental and physical health problems in receipt of benefits. On page 28 of the manifesto, under the euphemistic heading; "We will help you back into work if you have a long-term yet treatable condition”, they propose that; "People who might benefit from treatment should get the medical help they need so they can return to work. If they refuse a recommended treatment, we will review whether their benefits should be reduced.”
In other words, people with mental health problems, drug and alcohol problems, or who are overweight will no longer be able freely to choose to consent, or withhold their consent, to treatment. To decline a recommended treatment will result in benefits sanctions, and consequent misery and poverty.
This seems cruelly ironic, given that poverty and social inequality are significant contributory factors to many long term health and mental health difficulties in the first place.
This policy has been trialled before. Leading mental health professionals thought that they had successfully lobbied the Minister for Care Services, Liberal Democrat Norman Lamb, to reject the idea. Sadly it seems that Ian Duncan Smith has resurrected the spectre of the workhouses. Obey the rules, take the treatment and work for your dole, or suffer the consequences.
This policy is repellent. The suggestion that people should suffer financially if they choose to decline a healthcare intervention deemed to be in their best interests undermines a fundamental principle of medical and psychological healthcare, namely that of informed consent. A person who is capable of giving their consent has the right to refuse to receive care or services. It is wholly inappropriate to threaten the withdrawal of benefits in order to influence that decision. This is particularly true in mental health care, where therapy based on coercion simply will not work.
Leading professionals and academics have already united to oppose this proposal, in an open letter to the Conservative Party. We might perhaps hope that no properly regulated medical professional would touch such a policy with a bargepole. Perhaps that’s right. But exactly who will be relied on to deliver the policy – who will recommend, and who will deliver, ‘treatment’ - and will they be regulated?
An illness like any other
If we treat mental health problems, alcohol or substance use, and obesity as medical issues – as some do – then the issue is straightforward. Questions of coercion and professional conduct more generally clearly fall under the remit of medical ethics.
But I and many of my fellow psychologists and sociologists see such problems in a social, rather than bio-medical context.
Regulation and non-regulation
Crucially, clinical psychologists are statutorily regulated – so we are bound by our professional codes of ethics. Our professional code understands these subtle distinctions between the biomedical and social models - and still stresses the importance of consent.
The HCPC (which regulates psychologists) insists that; “A person who is capable of giving their consent has the right to refuse to receive care or services. You must respect this right”.
IAPT and other ‘cost-effective’ interventions
IAPT (the services established under The Improving Access to Psychological Therapies programme) is a good example of the social approach. They provide valuable services – as do other community services for people with drug and alcohol use problems, people who need to lose weight, etc.
Whilst some have criticised what they see as ‘cut-price’ services, I think on balance it is better to work with policy-makers to offer effective, and cost-effective, services to as many people as possible (surely a principle of public health and socialised healthcare).
But the possible challenges to the ethics of services delivery, including issues around coercion, may be sharper when our colleagues delivering the services are less well trained, and less regulated. Is it right that we should be ‘offering’ people interventions that are likely to bring people into benefits sanctions should they decline them, when the people delivering those interventions are not, in all cases, subject to statutory regulation?
Agents of the State
There can be benefits to moving services from the remit of expensive NHS professionals behind a referral wall and consequent waiting list, to a range of community settings, provided by NHS employees but also third-sector bodies, even commercial organisations contracted to the NHS, and also to other statutory agencies such as JobCentre+ and Probation, training their workforce in these kinds of interventions.
But along with the benefits there are also potential conflicts of interest. What happens where, for example, an employee of the Department for Work and Pensions (and therefore responsible for benefits sanctions) is also exploring, therapeutically, a person’s motivation for work?
These are complex issues. I believe in the wider and more cost-effective provision of services, and I believe in a psychosocial model. But I repudiate the Conservatives’ sanctions regime.
As well as, of course, arguing that any commissioning and service provision model should respect social justice, I also believe that we would all be better protected if all providers were subject to statutory regulation, such that there could be a sanction on any professional who did not respect the individual’s “right to refuse to receive care or services”.