I was signed off work five years ago. I had lost my job and was, unsurprisingly, feeling low; I went to see my GP, as I was having difficulty sleeping. Rather than dishing out a few sleeping pills, as I had hoped, my doctor googled the letters PHQ-9 on his computer and quickly went through the multiple-choice test for depression he found. Within a few minutes, I walked out of the surgery with a diagnosis of depression and a sick note stating that I was, in his medical judgment, unfit for work.
Looking at the Patient Health Questionnaire now, one thing immediately stands out: the copyright notice. The copyright in PHQ-9 was held by Pfizer, the pharmaceutical corporation — which, since it holds patents in antidepressants such as Zoloft, has a financial incentive in patients’ being diagnosed with depression. But it would be unfair to criticise PHQ-9 merely because it was developed for a private company; not when there are so many other criticisms to make.
PHQ-9 asks the patient if they have been bothered in the last fortnight by nine separate indicators of depression. The possible answers range from ‘Not at all’ (0 points) to ‘Nearly every day’ (3 points). Your points are added up at the end: the higher the score, the more certain the diagnosis of depression and the more likely that a sick note will be issued. The problem is not just that the scoring system is utterly transparent for anyone attempting to game it — the internet has more sophisticated quizzes to find out which Disney princess you are: you can’t ensure you’ll be Rapunzel by always going for option d — but that the possible indicators of depression are so broad that it is almost impossible not to have been bothered by some of them. Do you have trouble falling or staying asleep, reads one, or do you sleep too much? Both are indicators of depression, regardless of whether you oversleep — or undersleep — by ten minutes or ten hours. Do you have poor appetite or have you been overeating? Are you moving around more than usual or less than usual? I don’t suppose many people carry out regular audits of how much they sleep, eat or move about — I certainly didn’t. So I answered as honestly as I could, both then and whenever I returned to the surgery and revisited the test; and the scores didn’t show any improvement. If anything, they got worse — one of the questions was ‘Do you feel a failure?’ After 18 months on the sick, of course I felt like a failure. I remember thinking at the time that it was a reasonable analysis of objective reality rather than a symptom of depression.
Then I was summoned to be assessed by Atos Healthcare. You may have heard the name, possibly in campaigners’ slogans such as ‘Atos kills’ or ‘Atos doesn’t give a toss’. For the past seven years, this company has been evaluating claimants for Employment Support Allowance — the benefit for those whose mental or physical disabilities make them unfit for work — but has negotiated for the contract to come to an early end this month, because of the ‘reputational issues’ arising from it. Atos has become hated: a powerful symbol of austerity, a private company which profited from people’s misery (although Atos always insisted it had no financial incentives to find claimants fit for work) and overrode the medical judgment of GPs.
But I can’t hate Atos. I had a long interview — or rather conversation — with a chatty nurse, and a few weeks later received a letter from the Department for Work and Pensions saying that I had been found fit for work and my Employment Support Allowance was immediately terminated.
At the time, I was angry and upset; looking back, I realise that it was a turning point in my life. In fact, it was the best thing that could have happened to me. After nearly two years of health professionals telling me that I was unfit for work — unwanted, unvalued and unnoticed — I realised this wasn’t true; I rediscovered not just a work ethic but a purpose in life; and I began to resent the two years I had spent frowsting at home because a doctor had told me that was all I was good for.
Atos made mistakes, of course. At one point, its decisions were being reversed in four out of every ten cases taken to appeal. But most of the criticisms of Atos — that the Work Capability Assessment they undertook was ‘a crude computer test’, in the words of one MP, administered by examiners with little understanding of mental health — apply just as much to the PHQ-9 that put me, and others like me, on Employment Support Allowance in the first place. And none of the campaigners angry that it was a private company deciding who was entitled to benefit seemed to object when GPs outsourced their medical judgment to the Pfizer corporation.
Is my case representative of many claimants on Employment Support Allowance? Possibly not. I am very aware that I am privileged, and I would not have been able to move on from losing my ESA without the support of my family and a good deal of luck. (I am also now aware, following a quick glance at Wikipedia, that it is not good clinical practice to rely on PHQ-9 as a diagnostic tool, whatever Pfizer may say.)
But there is no reason to assume that the much-publicised failures of Atos — the claimants who died within weeks of being assessed fit for work; the jobseeker in a coma — are any more representative. They are the stories that are taken up by the media, of course, and touch public consciousness; the claimants or their families are, rightly, keen to publicise and rectify the mistakes Atos made. When Atos got it right, there’s no story: the claimant goes back to work and has no interest in letting anyone know that he or she was once declared unfit for work. (I am only prepared to tell my story because I no longer work in an industry where a diagnosis of depression is considered discreditable, or indeed unusual.)
And we need to tell our stories. The problem with ‘sick-note culture’ is not the financial burden of people claiming benefits to which they are not entitled — in fact, it would probably work out cheaper to accept that some claimants will game the system, rather than assess everyone who has been signed off by their GP — but the fact that the government is colluding in people wasting their lives.
Can anyone save the NHS?
Join us on 17 March to discuss whether anyone can save the NHS. Speakers include Andy Burnham, shadow secretary of health and Charlotte Leslie, member of the Health Select Committee. This event has been organised by The Spectator in collaboration with Pfizer. More information can be found here.