Disabilities and mental health conditions

I have chosen to examine the effect of UK welfare reforms across all disability groups for several reasons. The first of these is practical, as many official statistics do not separate people with disabilities into those with mental or with physical problems. The groups of people and their conditions that are contained in the category of ‘disability’ is fluid and has changed over time.^{Reference Roulstone3} Recent shifts have broadened the scope, adding people with mental health conditions, intellectual disabilities, developmental disorders and sensory impairments. This is reflected in our anti-discrimination laws: the Equality Act 2010 defines disability as ‘a physical or mental impairment which has a substantial and long-term adverse effect on the ability to carry out normal day-to-day activities’. The terminology is also reflected in the term ‘long-term conditions’, which applies to many of the people who are receiving sickness and disability benefits and are commonly users of health and social services. People with long-term mental health conditions are likely to be: living in households below the poverty threshold, to be in debt or have financial problems, to be in receipt of benefits, to be without a paid job and to live in social housing, and they are about three times more likely to have multiple social disadvantages than the general population.^{Reference Boardman, Currie, Killaspy and Mezey4} Many people who have mental or physical disabilities are on low incomes, they share common difficulties and are vulnerable to the effects of benefit changes.

Welfare reforms in the 21st century

The provision of services and income transfers by the state to meet the welfare needs of the UK population and the concomitant expenditure grew in the 20th century. These provisions include personal social services, services for healthcare, education and housing and income transfers such as pensions and out of work payments. One function of the welfare state is to protect people in times of hardship.

Most agree that the golden age of the British welfare state occurred after the Second World War, with rapid reforms to create a more comprehensive and universal welfare state with an increase in resources to extend benefits and coverage.^{Reference Pierson5} This was associated with a commitment to economic growth and full employment. The development of the modern welfare state has been a driver for the improvements in provisions for people with disabilities, including those for people with mental health conditions and intellectual disabilities.^{Reference Rose, Thornicroft, Szmukler, Mueser and Drake6}

The golden age declined in the 1970s, and the 1980s saw a period of retrenchment and recalibration, with an abandonment of full employment and cuts to welfare provision, despite continuing growth in public expenditure.^{Reference Pierson5} This was set against a background of increasing income and wealth inequality. In the late 1990s and most of the 2000s, the New Labour government's vision for welfare was for a system that enabled rather than provided. The challenge was to reduce worklessness and introduce new benefits and tax credits as well as introducing work support schemes. The recession in 2008 and the election of the coalition government in 2010 brought in a period of austerity and the introduction of further welfare reforms in 2012. The squeeze on expenditure and the roll out of the new benefits continue to this day, and the welfare state may face further retrenchment following the COVID-19 pandemic.

Changes in sickness and disability benefits

The two main direct payment benefits that are specifically aimed at people with ill health and disability are those that provide out of work payments (Employment and Support Allowance – ESA) and those that cover the extra costs of disability (Personal Independence Payment – PIP).^{Reference Galloway, Boland and Williams7}

ESA was introduced in 2008 as a result of the Welfare Reform Act 2007 and replaced Incapacity Benefit. Claimants for ESA are assessed through the process of the Work Capability Assessment (WCA) that includes face-to-face contact with a clinical assessor, who determines their ability to manage a variety of daily activities (physical and mental). The WCA process assesses whether a person is entitled to ESA based on their ‘limited capability for work’ (LCW) and their ‘limited capacity for work-related activity’ (LCWA). Those found to have LCW and not LCWA are placed in the work-related activities group (WRAG) and are expected to engage with job centre staff in seeking work. Those found to have LCW and LCWA are placed in the Support Group and are not expected to engage with work-related activity. For those in the WRAG, failure to engage with Job Centre staff can result in sanctions that may reduce or suspend benefit payments.

PIP, designed to replace the Disability Living Allowance (DLA) for people 16 years of age and over, was introduced as part of a range of benefit changes in the Welfare Reform Act 2012. Assessments for PIP, unlike those for DLA, are done by face-to-face interviews with a clinical assessor. Payment is given depending on the degree of difficulties experienced in activities of daily living and mobility.

Although these benefits represent the main direct payment to people with a range of disabilities, the 2012 Act also introduced further changes that have a significant effect on people with low incomes. These include: Universal Credit, the under-occupancy charge (‘bedroom tax’), a benefit cap and the up-rating of local housing allowance rates by the Consumer Price Index.

Universal Credit was introduced in an attempt to simplify the delivery of benefits and is a single monthly payment that applies to people who are looking for work or are on a low income. It brings together six working-age benefits: ESA, along with the income-based Jobseeker's Allowance, Income Support, Child Tax Credits, Working Tax Credits and Housing Benefit. It rapidly hit the headlines because of its delayed payments, and its full roll-out has been delayed.^{Reference Butler8}

Disability and poverty

Changes to the welfare state have effects on almost the entire population, but it is those on low incomes that are often disproportionately affected.^{Reference Hills9} This includes many with mental health conditions and disabilities. The latest figures on poverty in the UK (2017–2018) show that, of the 14 million people who live in poverty, 4 million have a disability and a further 3 million live with someone who has a disability. An estimated 13 million adults and children in the UK have a disability, 31% of whom live in poverty (the poverty rate among the non-disabled population is 20%). Nearly half of those who are disabled have a disability due to a mental health condition – for this group the poverty rate is 39%, compared with 30% among those with a physical disability.¹⁰ These figures have changed little over the past 8 years.

These figures reinforce the UN rapporteur's findings and point to a significant number of people with disabilities falling through the poverty safety net. It seems that benefits may not necessarily protect people with disabilities from falling into poverty.

Financial impact of welfare reforms on people with disabilities

Since 2012, organisations have warned about the impact of the cuts in benefits on people with long-term conditions.^{Reference Wood11,Reference Duffy12} Recent economic modelling examining the impact of the benefit changes since 2008 shows that disabled people have lost, on average, £1200 each year, compared with £300 for non-disabled people.¹³ The benefit changes have most impact on those with intellectual disabilities, social interaction difficulties and mental health conditions.

Problems with benefit assessments

From the start of its implementation, the WCA process was reported to present difficulties for those being assessed. The Citizens Advice Bureau (CAB) reported that the assessment was not effectively measuring fitness for work, often ignored independent clinical evidence and was producing inappropriate outcomes.^14,15 Claimants reported rushed assessments, inaccurate recording of their accounts and poor recognition of mental health problems.¹⁴ Many people report the process to be anxiety-provoking and a cause of deterioration in their health. The WCA remains widely condemned and seen in need of review.^{Reference Dwyer, Jones, McNeill, Scullion and Stewart16,Reference Baumberg17} Official Department for Work and Pensions (DWP) reviews of the WCA have questioned whether descriptors are fit for purpose and whether the assessment is sufficiently fair and effective.^{Reference Harrington18}

The Court of Appeal in 2013 judged the WCA to substantially disadvantage people with mental health problems and said that the DWP had failed to make reasonable adjustments to ensure that people with mental health problems were treated fairly by the system.¹⁹ Disadvantages for people with mental health conditions include: finding it difficult to report on the nature of their condition or the way that it affects their functioning; difficulty in attending for interviews or expressing themselves at interview; the fluctuating nature of their conditions, symptoms, impairments and functioning, which may be difficult to describe or to assess; the subjective nature of many mental health conditions; and the presence of coexisting physical health conditions.

The actual rate of incorrect decisions made at ESA and PIP assessments is not known. People can appeal their ESA and PIP decisions, but first they must ask for a mandatory reconsideration from the DWP. Few of these mandatory reconsiderations lead to a change in the award (around 15% for PIP). However, for those who go on to be seen by an independent appeals panel, the majority win their appeals. In 2019, 73% of ESA appeals and 68% of PIP appeals were won by the appellant.²⁰

The failure of the WCA and the assessments for PIP to reliably identify those who are eligible for benefits is costly, not only in financial terms but also in human terms.²¹ Removal of benefits is experienced by claimants as rejection, with applicants feeling mistrusted and invisible, coupled with the stress of being in a cycle of assessments, rejections and appeals.^{Reference Shefer, Henderson, Frost-Gaskin and Pacitti22} People describe experiences of their difficulties being trivialised or seen as fraudulent. Overall, people with mental health conditions are relatively disadvantaged when applying for PIP. For people transferring from DLA, the likelihood of being found not entitled to PIP was almost two and a half times greater among people with mental health conditions than among claimants with physical disorders.^{Reference Pybus, Pickett, Prady, Lloyd and Wilkinson23}

Many anomalies with the specific details of the assessments for PIP and ESA have been dealt with through the court system. In 2017, the High Court quashed the new government PIP regulations for mobility activities as they discriminated against people with mental health difficulties.²⁴ In 2019, the Supreme Court ruled on the scope of the term ‘social support’ in relation to the PIP activity of ‘engaging with others’.²⁵ In 2020, the Court of Appeal upheld two successful High Court challenges brought by individuals and found that the government had unlawfully discriminated against people with severe disabilities who had moved onto Universal Credit.²⁶

One high-profile result of the financial insecurity experienced by people on welfare benefits is the rise of food banks in the UK. Prior to the current COVID-19 pandemic, many of the people using food banks were those who had been affected by the recent welfare reforms, particularly those with disabilities, lone parents and large family households. A large-scale survey of people using food banks in 2016–2017 found that two-thirds had a health condition and almost one-third had a mental health condition.^{Reference Loopstra and Lalor27} Half of the households included someone with a disability – these households were three times more likely to use foodbanks than other low-income households.

Perhaps the most serious outcome of the WCA process is its relationship to suicide. It is known that the occurrence of completed suicide increases during recessions, but there is also good evidence that the government's programme of reassessing for ESA is independently associated with an increase in suicides.^{Reference Barr, Taylor-Robinson, Stuckler, Loopstra, Reeves and Whitehead28} There are also several case reports of the deaths of people by suicide or neglect whose benefits had been removed,^{Reference Ryan29} including the death of Errol Graham, a man with long-term mental health problems.^{Reference Butler30}

A recent report from the National Audit Office³¹ has revealed 69 suicides linked to the DWP's handling of benefit claims in the past 6 years. This is likely to be an underestimate, as the information held by the DWP on suicides is not exhaustive. The DWP is looking to improve the data collection and review process.

Conditionality and sanctions

The principle of conditionality (the attachment of behavioural conditions to the receipt of benefits) has long been part of welfare policy. It was, however, usually applied to recipients of unemployment benefits, who were expected to seek work. This has now changed, and under ESA regulations, conditionality is applied to sick and disabled people, many of whom are expected to engage in ‘work-related activity’ and who may receive sanctions, including the reduction of benefits, if they do not. The aim of conditionality for these groups is to help move people off sickness benefits into work. This has been combined with schemes to support people into work, such as the Pathways to Work and Work Programme schemes. The use of conditionality is widely debated and, as a policy, it ignores the barriers that people with disabilities face in getting into employment.^{Reference Dwyer32,Reference Patrick33} It is unpopular, often regarded as punitive, undermines social citizenship, is ineffective in moving people into work and can damage people's health, thus making employment less likely.^{Reference Baumberg34–Reference Reeves and Loopstra37} Disabled unemployment claimants are more likely to be sanctioned than non-disabled claimants.^{Reference Baumberg34}

Benefit stigma

Not only do people with disabilities associated with physical and mental conditions experience prejudice and discrimination linked to their conditions, they may also experience the stigma associated with claiming benefits and the shame associated with poverty. Overall, the UK public have low levels of understanding of the benefits system and people see the bulk of what the welfare state does as providing handouts to those who do not work.^{Reference Hills9,Reference Baumberg39} The largest proportion of the UK welfare budget is spent on pensions (42%), with 1% spent on unemployment benefits and 10% on incapacity, disability and injury benefits.⁴⁰ Overall, the public's impression is one of a system involving ‘Them and Us’.^{Reference Hills9} These dichotomies have pervaded the language of welfare. Traditionally, for the poor the division is between the ‘deserving’ and the ‘undeserving’ poor. In contemporary government policy. the rhetoric has been one of ‘a culture of welfare dependency’, ‘making work pay’, ‘scroungers’, ‘benefit cheats’ and the ‘hard-working majority’, which has been reinforced by newspaper headlines and television programmes such as Benefits Street. It appears that in the 21st century we have shifted our gaze from the ‘deserving’ and ‘undeserving’ to ‘strivers’ and ‘shirkers’.^{Reference Patrick41}

Effects on health and social services

Several recent reports have shown that dealing with people's benefit problems is putting increased pressure on mental health services and benefit and financial advice agencies^{Reference Clarke42,Reference Fairak43} . Community mental health teams are spending increased time managing patients’ practical problems, including benefits, debt, housing and employment. Practitioners are aware that it is difficult to treat people's mental illness without finding solutions to their practical problems, which are in turn having a significant impact on the patients’ mental health. Many of these problems require assistance beyond what can be provided by mental health practitioners, but accessing alternative forms of help and advice can be difficult, especially in the complex world of financial and welfare benefit systems. Nevertheless, access to help to resolve these practical issues is important to the patient's recovery and continuing engagement with health and social services (Box 1).