Incapacity benefit reform and the politics of ill healthBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1452 (Published 27 August 2008) Cite this as: BMJ 2008;337:a1452
All rapid responses
Bambra appears to be confusing illness with ill-health.
Circumstantial evidence ,  suggests that at least 75% of incapacity
benefit awards are on the basis of performance on the day of assessment;
what the individual says and does on the day, on their description of
their symptoms, and not on the basis of any objective pathology. People
have an illness when they feel ill; there is no need for them to have any
underlying pathology. When they have ill-health, the inference is that
there is an underlying disease process. The majority of those on
incapacity benefit do not have any significant disease process that would
explain their claims of incapacity.
We may well say that there is a high incidence or indeed prevalence
of mental illness today. This is simply a question of definition. We
have chosen to classify symptoms as a disease either in ICD10 or DSM IV,
particularly some mental health issues, but this does not mean the
individual has any underlying disease process . They have a problem,
and often need sympathy and support, but medicalising their symptoms often
causes harm. If someone is in debt, they may well be 'depressed' but a
sick note and SSRI will not address the cause, working to pay the debt off
As Bambra says, there is evidence that certified sickness and
incapacity benefit is a good indicator of health and mortality, but there
is good evidence that at least in part this is cause not effect; allowing
people to consider themselves ill, disabled and unable to work makes their
health worse. Getting them back to work improves their health .
Bambra is concerned that we may magnify stigma as a result. The real
danger is that we magnify stigma by medicalising normality. Most doctors
now recognize this as unhelpful. Society recognizes this because they see
someone who has a good circumstantial reason to feel low, but no clear
evidence of severe depression, so when that person appears with a sick
note saying ‘depression’ this is regarded with derision by managers. If
we were more discerning in our approach, so that we identified fewer, more
serious cases as ‘deserving’, society may be more willing to show sympathy
The reason why reform is happening is because society has decided
enough is enough. Society (= government) is tired of the cost of doctors
medicalising normality, and society has realized that for most cases the
best medicine is not pharmacology but money. Until recently individuals
have been motivated to prove they are ill for gain. Perhaps it is better
to motivate them to regain fitness and normality; it is our job to do so
with compassion and understanding. Those who stand to lose financially
may well cry ‘foul’ and make a fuss, but they will also get better and get
back to work. Is that really a bad thing?
Consultant Occupational Physician, Working Fit Ltd
1. Bambra CI. Incapacity Benefit Reform and the politics of ill
health. BMJ 2008;337:517.
2. A new deal for welfare: Empowering people to work, Cm 6730. 2006.
3. Halligan PW, Bass C and Oakley DA (eds). Malingering and illness
deception. Oxford University Press, UK. 2003.
4. Summerfield D. Depression: epidemic or pseudo-epidemic? JRSM
5. Waddell G, Burton AK. Is work good for your health and well-
being? The Stationery Office 2006.
Competing interests: No competing interests