Understanding Benefits Doctors and benefits Simon Ennals

Social security benefits seem to be constantly changing; virtually every year a new bill makes its way through parliament, with setpiece battles and behind the scenes skirmishes between the "poverty lobby" and the government. Each year at least one section of the claimant population seems to have to get to grips with a completely new system. All too often doctors and other primary health care professionals find themselves caught up in the web of confusion and administrative delays that beset the daily lives of an appreciable proportion of their patients. Not surprisingly, many doctors and others feel themselves ill equipped to understand the financial position their patients are inlet alone advise or help them to find their way through the system. In April 1988 a major reorganisation of the benefit system affected particularly the means tested benefits. Income support replaced supplementary benefit; family credit replaced family income supplement; housing benefit was severely cut back; and the controversial social fund replaced the one off payments available to supplementary benefit claimants with repayable loans and, for a limited number of people, community care grants. In 1989 there were major changes to the way people in board and lodging and hostels claim and receive benefits. In the next two to three years the changes in community care to be brought in by the National Health Service and Community Care Act 1990 will introduce yet more changes in the way the benefits system affects the most vulnerable patients. All of these key legislative changes have a fundamental effect on the benefits that patients are, or could be, claiming, and on the expectations of the role of doctors in the system.

This is the first in a series of 10 articles on the social security system in the United Kingdom and the part that doctors play in it.

Essential Rights, 94 Chaworth Road, Nottingham NG2 7AD Simon Ennals, consultant in welfare law Written in association with the Child Poverty Action Group BrMfedj 1990;301:1321-2 BMJ

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Poverty and health Perhaps the most fundamental factor that binds primary health care and social security together is illustrated by looking at the characteristics of general practitioners' patients. Jarman's work on underprivileged areas showed a close correlation between localities with a high deprivation score and areas identified by general practitioners as producing the highest workloads. ' The socioeconomic factors behind deprivation are also, of course, inextricably linked to poverty, low incomes, and dependence on benefits. Moreover the fact that so many aspects of the benefit system are directly linked to ill health and disability makes it inevitable that a high proportion of patients on many doctors' lists will depend on benefits to support themselves and their families. Many patients are poor because they are ill or disabled; many are more likely to be ill because they are poor. This places primary health care workers in a uniquely influential position in relation to patients' access to benefits. Health care professionals have a statutory role in the benefit system - that of providing medical evidence in support of certain claims -but they are also in a position to inform patients of what benefits may be available and provide information in support of claims.)

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Benefits Contributory benefits Retirement pension Widows benefit Unemployment benefit Sickness and invalidity benefits -see article 5 Maternity allowance-see article 8

Non-contributory benefits Child benefit Attendance allowance -see article 6 Mobility allowance-see article 7 Severe disablement allowance -see article 5 Industrial injury benefits-see article 9 Statutory sick pay -see article 5 Statutory maternity pay-see article 8

Means tested benefits -see article 3 Income support Housing benefit Community charge benefit Family credit The social fund-see article 4

Sorting out the detail of precisely what people are entitled to, and then paying it to them, is, of course, for the Department of Social Security. But the department can do its job only if people claim the benefits they are entitled to. Primary health care workers are particularly well placed to point out to people what they may be missing out on.

Providing information Attendance allowance provides a good example of this. Any member of the primary health care team may recognise when patients need the degree of attention or supervision that may qualify them for the allowance. Advising or helping them to make the claim may dramatically improve their income. The attendance allowance itself is worth up to £37.55 per week and, because of the way it also acts as a passport to additional payments of income support and housing benefit for disabled people, could lead to additional weekly payments of £15-£53 on top of the attendance allowance. Clearly such improvements in a patient's disposable income can have immediate effects on their ability to afford such things as better food, adequate heating, warm clothing, a telephone, and help with all the other hidden additional costs of disability. Research conducted by the Disablement Income Group among recent claimants of attendance and mobility allowances found that almost 25% of the sample had been told about attendance allowance by their doctors.' However, 48% had clearly been eligible 1321

Posters in surgeries, health centres, community health clinics, and outpatient departments patients ofbenefits they may be entitled to

can

remind

for some time before making their claim, and 20% had missed up to five years' benefit. Many in the sample had assumed that doctors would tell them about any entitlements that were related to the conditions they were being treated for, and 50% thought that doctors could do more to help. This role in providing information to patients was developed by Marks when discussing a survey conducted by Islington Peoples' Rights into the take up of benefits by the mentally ill.' He found that people being discharged from hospital were not necessarily being given adequate advice about relevant benefits, so half the patients in the sample were not getting the correct benefits, and 30% had debts and were suffering severe financial strain.

Statutory obligations Medical practitioners have a statutory role in providing medical evidence free of charge to support claims for some social security benefits: Schedule 3 of the new terms of service for doctors in general practice lists the relevant legislation covering all the main social security benefits. There has been some discussion

about how wide this obligation to provide medical evidence is, but at minimum it must involve confirming a diagnosis, treatment, and when necessary a prognosis when this is necessary to support a claim. Whatever the exact legal obligation, however, doctors are clearly in an influential position to help patients with appropriate claims by providing supporting evidence in a variety of circumstances. This could be at the request of the patient, of a welfare rights worker with the consent of the patient, or on the doctor's own initiative, realising that he or she may be able to improve a patient's chances of succeeding with the claim. Maximising the income of patients can be as effective in promoting health as many of the more traditional tools available to doctors. So what, in practice, can doctors do? This series of 10 articles is intended to provide up to date information about the main areas of the benefit system, giving practical information and advice for doctors and other health care workers to assist their patients to receive their correct benefit entitlement. More detailed information can be obtained from the Child Poverty Action Group's two handbooks, updated each year.56 Leaflets and posters produced by the Department of Social Security can be displayed in the waiting room or reception area. Important gains for individual patients can be achieved by looking out for the conditions that may lead to a particular benefit. One of the best ways of checking these conditions is by using one of the available computer programs. Entering a claimant's details in response to questions on the screen can provide an accurate and complete check of all the possible entitlements. One program, developed by Jarman and Blackwell, was specifically designed for use in general practice, is simple to use, and will run on most desktop computers.* I Jarman B. Underprivileged areas: validation and distribution of scores.

BMJ 1984;289:1587. 2 Jarman B. Giving advice about welfare benefits in general practice. BMJ

1985;290:522-4. 3 Buckle J. Informing patients about attendance and mobility allowance. BMJf 1986;293: 1077. 4 Marks BE. Social security benefits for the mentally ill. BMJ7 1988;297:1148. 5 Lakhani B, Read J. Nattonal welfare benefits handbook. 20th ed. London: Child Poverty Action Group, 1990. 6 Rowland M. Rights guide to non-means tested social security benefit. 13th ed. London: Child Poverty Action Group, 1990. *The program is currently available free from Lisson Grove Health Centre, Gateforth Street, London NW8 8EG (tel: 071 724 2391 ext 208).

MATERIA INDOMEDICA Smell of success Hilly slopes in many parts of India, notably those where plantations of tea or rubber abound, are full of leeches. Showers of rain bring them out in large numbers. Thin, almost stringy to start with, they have a fascinating gait. The front end anchors itself on the ground and the rear moves up to it. The rear now being anchored, the leech virtually stands up before lunging forwards to spread full length on the ground. The front end now anchors itself and the cycle is repeated. The unwary person passing by rarely notices when a leech attaches itself to the foot or leg. Often the first symptom is an itch, and when the eyes are turned down blood is seen dripping from the site where the leech has had its fill. When the leech is caught in the act, though, attempts at shaking it off or manually dislodging it prove notoriously difficult, giving rise to the term "to cling like a leech." The common remedy for ridding oneself of the leech has been salt. The Science Express published from Bombay on 13 February 1990 carries an account of an interesting new experiment. Ms L Thankamma at the Rubber Research Institute of India in Kottayam, Kerala, focused on garlic, which is known to repel insects and reptiles. She prepared garlic

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paste in gingelly oil and applied it to the lower limbs. This did keep the leeches off, but was washed away by the rain. "So I wanted to try the action of garlic when it is eaten and its odour exudes from the skin after being digested. I cooked a table spoon full of garlic in gingelly oil and took it at 5 o'clock in the morning, assuming that it would get digested in ... 4 to 5 hours." She and an assistant (who had not taken garlic) started work in the wet fields around 9 am. When they broke for lunch the assistant had on his ankle a leech bloated with blood and another yet to commence its meal. Ms Thankamma was free from leeches. She detached the leech from her assistant (perhaps by breathing heavily on it) and permitted it to lope along the ground. She placed some garlic oil paste along its path and saw, again and again, that the leech veered off abruptly to evade the all pervading odour of garlic. If, then, you wish to stroll through tropical forest or wooded slope and remain free from leeches, you could do worse than munch a couple of cloves of garlic well before you start out. This may, of course, repel some humans as well but that may be all to the good. -SUNIL PANDYA

BMJ VOLUME 301

8 DECEMBER 1990

Doctors and benefits.

Understanding Benefits Doctors and benefits Simon Ennals Social security benefits seem to be constantly changing; virtually every year a new bill mak...
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