Those receiving disability benefits have suffered disproportionately from the austerity measures

Editor – There has been much debate about the causes, precipitating factors and management of the financial crisis. However, it is clear that a major factor has been the spending by governments and individuals of money that they do not have. Therefore the solution must include a return to financial probity. A major contributor to the fiscal deficit is social expenditure and this must be reduced to balance the budget. Many of those receiving benefit have suffered disproportionately from the austerity measures that many feel are necessary. So it is not only just, but also essential, that claimants, new and old, be treated both compassionately and realistically during reduction of the benefits budget.

Over the last few decades the disability expenditure has tripled at a time when the ability to treat disease has improved, so the increase cannot be due to failure of treatment. Change in the age profile of the working population might be partially responsible and the drift from physical to intellectual demands might work either way. Neither is likely to be a whole answer, but I believe the principle cause is deconditioning. In many chronic conditions the relationship between objective findings and performance is poor. To give an example from my own respiratory practice, I have seen patients with identical FEV1s whose sole complaint is an inability to carry guns across a heather moor or to run briskly playing tennis, while others are genuinely limited to 30 m walking on flat ground. The exercise limitation in the latter cannot be directly due to the respiratory impairment, but is due to a vicious circle of decreasing activity and increasing breathlessness – in other words deconditioning.

Deconditioned subjects are not malingerers, albeit often labelled as such, because by the time that they reach that stage they are actually disabled. The medical profession makes a major contribution by not recognising the need for aggressive rehabilitation at the earliest stages of chronic disease. Indeed habilitation is a better term, emphasising that attempts at rehabilitation during the late stages may be too late. The benefits system should recognise its contribution to the problem, which is a particular hazard during times of financial depression. It should facilitate and require attendance at (re)habilitation programmes, with frequent reassessment until the performance threshold is reached. It should also emphasise that Disability Living Allowance is not a long-term sickness pension, but, as its name implies, financial help for the disabled to reach full potential including employability. Similarly, benefits contribute to social deconditioning among the unemployed. In response to this the unemployed must be given the opportunity to experience work, but they in their turn should be under an obligation to accept it. One of the barriers to this is the perceived indignity of working for nothing. This would be mitigated if the benefit were presented as a state wage for the unemployed. Then like all wages it should be taxed or withdrawn fairly at no more than one pound for every three earned.

Both health and benefit sectors must recognise that deconditioning, and not impairment, is the determinant of limitation of performance in many subjects and they must act accordingly. If the immediate use of resources to reverse the latter for long-term benefit is to be acceptable to the tax-payer, the public must be educated to accept that the major toll on the disability budget is not fraud but deconditioning.

• © 2013 Royal College of Physicians