Benefits for people with mental illnesses

I helped out today at a consultation event arranged by SAMH, the Scottish Association for Mental Health.  Their latest report focuses on Personal Independence Payment, and the experiences of people with mental illness claiming the benefit.  The report is based on comments from claimants, who felt disbelieved and stigmatised, and had no trust in the process.  The people I spoke to today had been treated as if their benefits were all to be judged on their capacity to work, and as their capacity to work was judged by their ability to do things physically, they weren’t entitled.  Assessors seemed not to understand, one participant explained eloquently,  that an invitation to explain what things were like at the very worst was equivalent to a request to revisit hell.

Mental illness poses a whole series of issues for benefits, which are not ideally covered by an emphasis either on disability or on long-term illness.   What should benefits for people with mental illness look like?  The benefits have to cover lots of possible contingencies – among them,

  • meeting income needs
  • offering social protection/insurance
  • support for carers
  • income smoothing
  • support while out of work
  • social inclusion
  • compensation for long-term low incomes and disadvantage
  • support for rehabilitation
  • facilitating employment
  • promoting engagement with medical services
  • protective income while in hospital
  • providing social care

As usual, most of these objectives have little do with the world of work – getting people into the labour market has only a limited role, as it does in lots of other benefits.

There is some limited reason to think that people with mental illnesses face higher costs, too, but the basic case for benefits is not based on extra costs.  Alf Morris MP, defending the introduction of Attendance Allowance, argued that the purpose of such benefits was to invest people with dignity.

“It is not only a question of finance we are discussing, but also the dignity of disabled people. … This provision must be seen as only part – a very minor part – of an entirely new financial deal for the severely disabled. … This is only one stage towards improving the financial status, and therefore the dignity, of every one of our severely disabled fellow citizens.”

That is as valid now as it ever was.

Questions are raised about the validity of the WCA

I’m intrigued, but not convinced, by Jonathan Hume’s analysis of the Work Capability Assessment in the new edition of Radical Statistics.  He identifies a significant bias against claimants in poorer and less healthy areas. “Counter-intuitively”, he writes,

healthier areas were finding claimants fit for work less frequently and placing claimants into the Support Group  more frequently. This is the opposite of what would be expected of an accurate test of disability.

I’m not sure that his expectations are right.  The numbers he’s been processing are not about what happens to people with disabilities, but what happens after claims for Employment and Support Allowance, which is a long-term incapacity benefit.  In areas of higher employment, there should be fewer people of working age with disabilities (because people with disabilities tend to suffer lower long term incomes and can’t afford to live in the more salubrious areas), but the disabilities which do lead to ESA claims will tend to be more serious, because people with lesser disabilities have more opportunities for employment than they do in poorer areas.

What he does establish, however, is that there are unexplained variations between areas, and clear biases in the outcomes of WCAs – for example, that more people are placed in the Support Group when more WCAs are done.   The WCA was developed on the basis of a population-based assessment, and if it’s producing inconsistent results at the level of the population, that does raise questions about its validity.

Rethinking disability assessments

Jeane Freeman, the Scottish minister for social security, has declared that rethinking disability assessments will be a priority for the new administration.  I haven’t dealt with this issue in my draft submission – I needed to cut down the length, I’ve had other opportunities to put the argument and in any case they’re on it.   None of those is a reason not to cover the issues here.

As things stand, nearly everyone who claims is being assessed.  According to the National Audit Office, the DWP had initially intended 75% of all claimants to undergo face to face assessments for PIP, but the actual rate has been 98%.  Most assessments relating to disability are pointless.  They either confirm the obvious or they duplicate information that is already held.  We can do something about that.  The problem is that some assessments are necessary: many people with disabilities cannot say whether they are disabled or not, and have no idea whether or not their disability fits the criteria for benefits.  Any general rule, no matter how sensitively it is administered, is going to have to deal with some grey areas.  But the same approach does not have to apply to everyone: the Scottish Government has the power greatly to reduce the numbers of assessments, by adapting the procedure to the circumstances.

First, it is possible to identify certain conditions which should imply automatic entitlement, offering benefits on minimal or secondary evidence – either accepting on sight that the person has a qulaifying disability (double amputation, severe disfigurement) or passporting benefits on the basis of provision by other agencies (congenital disability, blindness).

Second, there are conditions which will have led to prolonged long term contact with health services, and certification from a consultant is sufficient to establish that the condition is there without requiring further detailed examination of personal circumstances. Examples are terminal illness, multiple sclerosis, MND, malignant neoplasms or brittle bones.

Third, there are conditions where existing services in long-term contact with the individual are far better placed to judge the impact of a condition than an independent assessor could be, and it would be appropriate to accept medical certification. Examples are continued psychosis, epilepsy, dementia and learning disability.

In all three categories, there will be some which should receive a long-term award or whole-life award and will not require reassessment. (Additional note, 2nd October:  this point has now been conceded by the DWP, but the minister has  also said that the ‘vast majority’ will continue to be assessed.)

Only after these three categories are considered is it appropriate to think in terms of further individual assessment. The points scheme currently used in a range of benefits was initially developed from work done by the Office of Population, Censuses and Surveys to establish the range and severity of disabilities in the UK. That study validated the approach through a range of tests, but it pointed to an important conclusion: that once the primary disabilities had been identified, it was very rare for further disabilities to make any notable difference to the findings, and that information served no useful purpose. It follows that it is neither appropriate nor necessary to ask most claimants whether they can go to the toilet unaided.  The question is embarrassing and the information obtained is for the most part irrelevant. The assessment process should begin by asking people to identify their most important disabilities, ask questions about those, and go further only in marginal or complex circumstances.

Finally, there will be a residual category of people who are not adequately dealt with by any of the four stages above, and who will require or ask for a more thorough comprehensive assessment. This category should be small.

After IDS

It’s difficult to know what has motivated Iain Duncan Smith to resign.   He claimed he was dissatisfied with the cuts to PIP, but suggested at the same time they might have been justified if they had gone towards deficit reduction.  That makes little sense.  If the government was serious about deficit reduction, it would have increased taxes.  So in both cases, benefit cuts have been made necessary in order to protect the incomes of people who are better off.  Apparently he was also frustrated because he was unable to cut payments to pensioners.  So one possible explanation is that IDS felt he should have full control, rather than being subject to the constraints of the Treasury.

A second possibility is that IDS thought it prudent to go before things unravel.  Universal Credit is not working, but the model that IDS said he believed in – a benefit that would be paid regardless of work status – has been fatally undermined by sanctions and the cuts to the Work Allowance coming in in April.  A court decision last week should require the DWP to publish information on the early development of UC, and that is likely to reveal a combination of managerial incompetence and misleading statements to the Commons.

Either way, Stephen Crabb, the new Secretary of State for Work and Pensions, is inheriting a pig’s breakfast.  There could be scope to review and simplify some of the policies that have incapacitated the benefits system in recent years:

  • decouple Housing Benefit from the Universal Credit reforms
  • individualise claims, rather than expecting couples to make joint statements online
  • exempt select categories of need from redundant assessments
  • relate means-tested benefits to previous periods, rather than to uncertain current income
  • limit any sanctions to a proportion of benefit, so that contact is not lost
  • address the inconsistent treatment of provision for mobility between people of different ages.

However, if – as seems likely – he has been given the brief to impose more cuts, it can only get worse.





The Budget hints at reform of disability benefits

There’s very little in the Budget directly on benefits – the main things are on page 103.  The main point of interest is probably about benefits for disability, and two of the three points are pre-announced.  The first is a modification of the PIP assessment to reduce credit for using aids and appliances.  As we’ve seen relatively few PIP assessments so far, it’s difficult to know how much effect this will have, but I suspect the government’s prediction that it will exclude huge numbers of people will have to be set against other changes in rules relating to fluctuating illnesses and mental health.  Tightening rules rarely works as governments expect.

The change on supported housing has bought a year for specialist agencies before the cuts come, but it’s only a moratorium.

The third point is the vaguest, but it could be the most important.  The government wants to consider “the case for long-term reform of disability benefits and services that is fair for the taxpayer and for those with disabilities or health conditions”.  I’ve no idea what that means, but  the implication of that phrase seems to be that they think the present system is unfair to taxpayers and costs too much.  Most people who become disabled have been taxpayers, and what they pay is supposed to ensure social protection for them when things go wrong.  Depending on how you count, there are something like eight to ten million people with disabilities in Britain.  Most of us will know someone in our own family who has been disabled or ill for a long time, and many of us could be disabled ourselves in time to come.  We should be telling people: it could happen to you.

The disability clauses in the Scotland Bill

The Devolution Committee of the Scottish Parliament has published a lengthy report reviewing the provisions of the Scotland Bill.  I get a brief mention, because I was asked to submit evidence about the fiscal framework, but I want in this entry to address a different issue, concerning the clauses about disability.  As it stands, the Bill has five distinct definitions of disability:

  • two definitions deriving from the definition of a disabled person as someone receiving a disability benefit, which is

a benefit which is normally payable in respect of—

(a) a significant adverse effect that impairment to a person’s physical or mental condition has on his or her ability to carry out day-to-day activities (for example, looking after yourself, moving around or communicating), or

(b) a significant need (for example, for attention or for supervision to avoid substantial danger to anyone) arising from impairment to a person’s physical or mental condition

  • a recipient of Severe Disablement Allowance,

a benefit which is normally payable in respect of—

(a) a person’s being incapable of work for a period of at least 28 weeks beginning not later than the person’s 20th birthday,
or  (b)
a person’s being incapable of work and disabled for a period of at least 28 weeks

  • a reference in the provision for carers, which is to a disabled person as

a person to whom a disability benefit is normally payable

  • and a completely different reference in clause 31 on employment support, where

“disabled person” has the same meaning as it has in the Equality Act 2010

I put it to the Devolution Committee last year that these definitions were not adequate.  I wrote then:

“The Smith Commission proposed the devolution of powers relating not only to disability but to those who are ill.   The use of a more restrictive definition is a matter of concern to some agencies working with disability, such as the Multiple Sclerosis Society and the Scottish Association for Mental Health. The use of the Equality Act definition of disability would have automatically brought in some classes of illness, such as people with multiple sclerosis or HIV/AIDS; the new definition does not.”

Subsequently the Committee received assurances from the Secretary of State, and those assurances are the ones included in their final report.

“344.  He explained that the reason that there is a variation in definitions used for disability between clause 19 and the clause relating to employment provisions is to accommodate different devolution issues. The UK Government’s view is that the Equality Act 2010 definition would not be appropriate for clause 19 and, indeed, could put limits on the Scottish Parliament’s ability to decide who is, and who is not, covered by their provisions relating to disability benefits. The definition used in clause 19 is designed, in the UK Government’s view, to cover the adverse effects or needs arising from an individual’s health condition or disability, with the proviso that these effects or needs must not be short-term.

345.  The Secretary of State concluded by noting that the inclusion of the phrase “normally payable” gives the Scottish Parliament the necessary flexibility to create exclusions or to create special categories, for example to enable provision for people who are terminally ill. The phrase “normally payable” was explained in more detail by the UK Government. It said, “The phrase “normally payable” is designed to provide sufficient flexibility to enable provision for exceptional cases – for example it would enable provision to be made to prevent the payment of benefit in situations where a person is temporarily accommodated at public or local expense in a care home or is receiving free in-patient treatment from the NHS or to enable the payment of benefit in situations where a person is terminally ill.

Only the courts could ultimately decide whether or not these statements are true, but while there is some force in the first paragraph, the second has to be wrong.  The disability clauses are not defining the scope of Scottish benefits; they are defining the powers of the Scottish Parliament to legislate in this field.  All the clauses on social security start from the principle that the Scottish Parliament has no powers relating to social security unless and until those powers are explicitly granted.  The Scottish Government  has no right to assume that if a benefit is ‘normally payable’ under one set of circumstances then that carries the implication it  might also be treated as payable in different circumstances.  A person might be terminally ill without meeting either of the key criteria in s 19, and if that was true,  the Scottish Parliament would have no right under these clauses to create a benefit.

In the absence of opposition from central government, it is unlikely that this would ever get to court.  The main stumbling block is likely to be the Scottish Parliament’s own lawyers, who are quite properly concerned to work strictly within the rule of law, and have blocked legislation that is outwith the Parliament’s competence before.   It may still be possible to use the other powers in the Bill – the power to create new benefits or to top up reserved benefits – to cover the contingencies that have been left out.  (This was not an option when I made my submissions a year ago, but it is now.)  It would have been so much clearer, and so much easier, if we were not dealing with such restricted and muddled definitions of disability.

The NAO expresses concern about disability assessments

The National Audit Office has expressed concern about the management of contracts for the assessment of people on ESA and PIP.  98% of claimants for PIP have been receiving face to face assessments. They are critical of ” a cycle of optimistic targets, contractual underperformance and costly recovery”.

The DWP has been quite clear about its reason for doing so many assessments:  they save money.

“The Department introduced a target of 1 million ESA assessments to be carried out in 2015-16. It told us it derived the non-negotiable target from the number of assessments needed to achieve expected benefit savings rather than from discussions with bidders or modelling of the possible number of assessments.”

Assessments do save money.  Some people would say that that’s because people aren’t really entitled, and the assessments find them out; but it’s just as likely that the assessments are counting people out for the wrong reasons, such as not getting to the interview, not understanding the tests, or relying on the wrong sort of evidence.   The assessments are slow, intrusive, and presumptuous (they overrule extensive medical evidence about people’s situations over time).  We ought to be asking whether assessments are really the right way to save money, or whether we need to review the rules so that the benefits make more sense to everyone.

Problems with PIP

The Personal Independence Payment , which is being introduced to replace Disability Living Allowance, is supposed to refocus the assessment on people’s capacities.  It’s not clear that it does that.  What it does do is to make the whole thing much more of a tick-box affair, similar to the assessment of ESA, and like ESA tending to disregard supplementary evidence from professionals who know what’s happening.  Some of the welfare rights officers I was listening  to this week, at CPAG Scotland’s welfare rights conference, didn’t mind too much; standardisation makes the whole thing more predictable, even if it doesn’t exactly do what the government thought it should, personalising benefits more sensitively.

In a court case reported ten days ago, the delays in the delivery of PIP were roundly condemned.  The two claimants had been waiting for ten and thirteen months.  The DWP is suggesting that the delays are now down to seven weeks on  average, but that figure might not cover the length of the whole process, and there may still be very long delays in particular circumstances.  I understand  that there are more likely to be problems when home visits and needed, and so in remote and rural areas.  Welfare rights workers were saying that it could help to rearrange assessments at distant centres – which is useful to know for claimants in difficulty, but it’s hardly a triumph.

The delays, could, and should, have been avoided.  The fundamental problem with PIP is that it relies on individual reassessment, based on the model used in ESA.  The plan is to have something like three and half million assessments by 2018.  In principle, there was some allowance to excuse some claimants, possibly up to a quarter; but in practice, according to last year’s National Audit Office report, there are face to face assessments for 97-98% of claimants.  They needed to go in the opposite direction.  The main way to do that is to reduce the number of face to face assessments, and there is an easy and fair way to do that without compromising the principle of individual assessment – start accepting medical evidence.

Cutting £12 billion from benefits

A leaked document, mentioning a few possible cuts to benefits, has been widely reported.  I’d previously commented on some ideas floated by Iain Duncan Smith, including cuts to large families, refusing benefits to immigrants and limiting the welfare cap.  Regardless of their popular appeal, these are no way to make major economies – they address imagined problems, and there’s not much money to be saved from cutting benefits that aren’t being paid in the first place.  The new list is rather more serious:  limiting the scope of carers’ benefits, transferring the burden of the industrial injuries scheme to industry and making disability benefits taxable.  These still wouldn’t save £12 billion, but (for a change) the ideas have obviously been compiled  by a team who actually know how the benefits system works.  The Financial Times reports that the DWP team has been working to directions from Sir Jeremy Heywood, head of the Civil Service.

The government has been eager to disown the document.  “It’s wrong and misleading”, a spokeswoman for Iain Duncan Smith said, “to suggest that any of this is part of our plan.”  There has been no official explanation of where the government thinks £12 billion could be cut from benefits.  That’s unusual in a Budget, which tempts me to speculate that the Chancellor might not have had the agreement of his coalition partners to the projected savings.  But the explanation might be simpler:  with the election looming, telling several million disabled people and their families that their benefits are about to be cut may not be  the smartest way to go.

Some thoughts on disability benefits

After my session last week for the RNIB, I was interviewed on Insight Radio.  You can hear me blathering about disability benefits here. The podcast (nearly 11 Mb) covers two main themes: the implications of the devolution of benefits for people with disabilities, and some of the ways that disability benefits might be delivered more simply.