Over two million (1) people in the UK were claiming Employment Support Allowance (ESA) in 2018. This is money paid to those who are prevented from doing any form of paid work by their medical problems. The current rate is between £73.10 and £110.75 (2) per week.

For the majority, they will have had a 'work capability assessment (WCA)' which was introduced in 2008. These assessments are conducted by a healthcare professional, usually a nurse or physiotherapist, but for more specific and complex conditions a doctor is required.

I do a combination of assessments in setups like a GP surgery, and home-based assessments for people who are too unwell to travel. I spend about 45 minutes with each client. As in some areas of psychiatry, the word patient is usually avoided. Much of what I do is like a medical clerking, with a full medical history, and relevant examination. But unlike a hospital clerking, I will enquire about their 'typical day', which forms a narrative of how conditions affect function, what things they particularly struggle with, and what kind of adaptations or assistance is needed.

Once the client has left, I spend about 30 minutes writing up a report, which is then sent to the Department for Work and Pensions (DWP). The point is never to dictate specifically that someone is fit to work or not, however there are 17 areas of physical and mental health functions that must be addressed. Much of this can be nuanced, with function varying day-to-day, and so a requirement that each activity can be completed 'repeatedly, reliably and safely' is considered. Also considered are those who may be functioning well overall, but for whatever reason may be placed at significant risk if expected to work. This could include those on the vulnerable adults register, or in a particularly fragile physical or mental health state.

So that's the nuts and bolts of the job, but more commonly people want to know why? Why isn't my GP deciding this? Why are we bothering to do this in the first place?

First, why don't GPs complete the assessment? Well the WCA was brought in because pre-2008, very few people were required to attend any form of assessment and it was mostly GP medical certificates that were used. However, many of the 'disabling conditions' that were presented were either minor (such as sinusitis) or generally asymptomatic (such as high blood pressure), and were unlikely to cause significant disablement over a period of months or years, but such patients were still entitled to incapacity benefit (remembering those who are off sick with short term conditions are entitled to statutory sick pay).

This isn't a knock against GPs, but let's remember their appointments are ten minutes. In all but the most severely disabled, it's unrealistic to expect an assessment in this time frame, and GPs rarely get significant information about levels of function over an extended period. Part of the evidence for this is that whilst in many cases a GP opinion is sought by a letter sent to them before the assessment, many are not returned, or simple come back as 'unknown'. Sadly, for most of us, the days of family doctors that know us intimately from birth to death are gone.

The other issue with GPs is that it is a struggle to remain impartial. Whilst the generational GP may be a dying breed, it is still important to good care that they have some form of rapport with, and trust from patients. This is at odds with a system which is meant to be impartial. I suspect that some of the 'not-known' replies I receive are from GPs who wish to avoid being untruthful, but may also be aware that their information may not be supportive of their patient being awarded ESA.

Second, why do it at all? It is widely recognised that work is generally good for people, (3) that it meets psychosocial needs and is central to economic means, identity and social roles and status. Unemployment conversely is associated with poor health and higher mortality, and that those who move off benefits into work and re-employment gain the health improvements shared by those in work. However, it is also well recognised that for a minority, work is in fact detrimental and systems to identify those people need to be robust and easily accessible.

This fits with a biblical understanding of work being dignified and given by God, who we see rests following his work of creation in Genesis 1. Adam and Eve are given the work of subduing Eden in Genesis 2, and Jesus in John 5 says, 'my Father is always at his work to this very day, and I too am working'(John 5:17). But we also live in a fallen world and since Adam and Eve were cast out from Eden, sickness and death have entered the world. We also live in a society where resources are finite, and decisions about how to manage those resources in a fair and effective way must be made.

Some have made complaints that the WCA is a tick box exercise, and that's partly true. But so is getting a mortgage or credit card, antenatal care, or buying groceries, all of which are important parts of living together in society. Without a search for truth, justice for the vulnerable cannot be had, (4) either from a system that is too punitive or simply turns a blind eye to exploitation. To my mind, this makes this a vital area for Christian doctors and nurses to be present. Often with a multitude of conditions, disabling effects can be much more subtle than a missing limb. Without the correct skills and dedication, those unfit for work can often be unfairly treated or disenfranchised. In a world where growing greed can be found in all places, there is a biblical imperative both to speak up for the vulnerable (5) and resist the wolves among the sheep.

James Howitt is a doctor who performs Work Capability Assessments and a CMF Associate Staff Worker in Essex