Disability Assistance: the consultation paper opts for too many of the wrong answers

The Scottish Government has launched A Consultation on Improving Disability Assistance in Scotland, with a closing date set for the end of May. The consultation paper makes the important assumption that the design of Disability Assistance should be based broadly on the existing pattern of benefits.  In particular, it proposes

  1. A distinction between benefits for children and young people, for people of working age and for older people
  2. The continued use of a functional assessment, and
  3. The maintenance of components to cover ‘daily living’ and ‘mobility’

A risk of confusion  At three points (on pages 15, 16 and 17) the document suggests that they want to reduce the “risk of confusion between benefits being delivered by both UK and Scottish Governments”.  The existing system of benefits is already deeply confusing, and as a consequence it fails in many important respects to reach the people it is meant to help. The approach laid out in the consultation paper is designed to make sure it is at least as confusing as it was before.

I would point here to three pieces of evidence.  The first is from an ad hoc study done for the DWP.  Three-quarters of the people who benefits are supposed to support do not recognise themselves as being ‘disabled’.  Most of them do not think of themselves as being disabled; others answer that they’re disabled ‘sometimes’.   The second is that people do not understand the basic premise of a benefit that is supposed to cover daily living or care.  A study of unsuccessful claims for Disability Living Allowance found that people receiving Employment and Support Allowance – the long-term sickness benefit – did not understand that DLA was there for different purposes from ESA; that they sometimes made claims with no reasonable hope of success, thinking that they may as well have a crack at it anyway; and if they were refused, they put it down to luck rather than the operation of appropriate criteria.  The third issue is that takeup of these benefits is worryingly low.  None of these figures is certain, but the best guesses are that the mobility component of DLA is claimed by something in the region of 60% of the people entitled, Attendance Allowance by 50% and the care component of DLA (now the ‘daily living’ allowance of PIP) is taken up by 40%.

Distinctions on the basis of age.  Wherever a distinction is made on the basis of age, there will be problems in managing the transition between benefits.  The suggestion that people of “working age” have different needs tends irresistibly to give the impression that the criteria have something to do with working, and one of the problems with PIP at present is the mistaken assumption that ability to work is somehow a relevant criterion in assessment – that is not what disability assistance is supposed to be about.

The most important problem, however, is that distinctions on the basis of age can lead to serious inequity, and anomalies in the operation of the benefit.  As things stand at present, people under the age of 65 get PIP, and people over the age of 65 are supposed to get Attendance Allowance.  That implies, on the face of the matter, that people under 65 can get help with mobility, and people over 65 cannot.  However, that is not what happens.  A person who becomes disabled before the cut-off date can continue to receive DLA/PIP after the date.  Fully a third of PIP and DLA claims are made by older people under this rule.  And that means that people with the same disability can get different benefits, depending on when their disability was incurred.  One of the most common causes of disability for people aged 50-70 is stroke; some people who have strokes recover, some others recover partially.  So a person who had a stroke at 63 and recovers partially may get help with mobility, while another person who has a stroke at 67 cannot, even if the functional limitation of the older person is more serious.

The use of a functional assessment. DLA was made by clumping together two rather different benefits: Attendance Allowance for adults below pension age and mobility allowance.   Mobility Allowance was based on a functional assessment – whether or not people could walk; Attendance Allowance was not.  While there have been many challenges to the mobility component, for example those related to conation, it is the care or daily living component which causes most confusion.

The points-based approach to functional assessment was initially based on work by the Office for Population Censuses and Surveys, when the scheme had a very different purpose.  There was no intention to develop a mechanism for individual disabilities to be precisely measured, and points were not the sole test: when the OPCS scheme was initially worked out, one of the critical points made about it was that disability reflected the nature of each person’s most serious impairments, not a cumulation of smaller functional limitations.  The points scheme has never worked well, and one of the reasons why entitlement to DLA and then PIP grew beyond the government’s expectations was that repeated challenges drew attention to groups of people who were simply left out – first people with learning disabilities, then mental disorders, then people with terminal illness and most recently people with fluctuating conditions.  The central problem is simply this: most disabilities do not have a strict, constant and precise relationship to functional capacity or daily activity.  People cannot clearly relate their circumstances to the tests.

There are alternatives.  I have made the case before on this blog, and it bears repetition here.  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 qualifying 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. Only after these three categories are considered is it appropriate to think in terms of further individual assessment of function, or a points scheme.

Daily living and mobility components. The other main issue to consider is whether there should be two components of a combined benefit, at least for people of working age.  The key problems have already been identified here.  People do not understand it, and ‘have a go’ instead; takeup is poor; there are serious inequities because of the treatment of the mobility component.  If there was a separate Mobility Allowance, its rules could be reconsidered to sort out which older people should get it, instead of the arbitrary current rules; and people do understand, more or less, what a Mobility Allowance is about.  Then we could have a reasoned discussion about the other component – whether it is supposed to respond to extra needs, or to provide extra income, some compensation for disability, or some other purpose.  (My own view is that we ought to revive SDA, rather than abandoning it, but I appreciate that that probably puts me in a minority of one.)

Whatever we do, we need to recognise that the current arrangements do not work, and that minor tweaks are not enough; it is time to bring them to an end.

Policies for devolved disability benefits

The Scottish Government has decided not to ask for the transfer of responsibility for Severe Disablement Allowance, which will continue to be managed by the DWP. I was asked by a journalist for a reaction, and what follows is my answer.

The decision is  understandable, because SDA was closed to new claimants many years ago, and the government does not want to create disruption for the small numbers of people who are currently entitled to Severe Disablement Allowance. Having said that, the power to deliver a benefit similar to SDA could be important for the future. SDA was always a relatively small, residual benefit designed to fill in the gaps when other benefits were not available. The distinctive feature of SDA was that it was the only benefit paid to people simply because they were severely disabled. Other benefits like Attendance Allowance, DLA and PIP have tied the conditions to people’s care needs, which usually means, for example, that people in residential care may not get them. I think it’s valuable to have a mechanism of the sort, and hope that the Scottish social security system will be able in the future to recognise needs that the current UK system doesn’t.

More generally, I’d also like to see benefits for people with disabilities to be made more accessible. The proposed reforms will make it possible for older people to continue to receive Personal Independence Payments without repeated assessments, and that’s a good thing. But the basic reason why older people are continuing to claim DLA or PIP, instead of moving on to Attendance Allowance, is that Attendance Allowance doesn’t cover mobility needs. This means, for example, that someone aged 63 can get long-term mobility support after a stroke, but someone aged 67 can’t, even if the restrictions the older person faces are more severe. It would make more more sense, and it would be fairer, to have a separate Mobility Allowance without the age restrictions that currently apply.

PIP is costing more than DLA did. Why is the OBR surprised?

Personal Independence Payment has proved to be more costly than the system it replaced.  If only we had realised, the Office for Budget Responsibility complains, we shouldn’t have accepted that PIP would deliver the savings that the DWP was predicting.

“At the time of its use in our December 2012 forecast, the results from [the DWP survey] appeared the best available guide to the assessment process. But hindsight has revealed several issues with the nature and use of the results …  including: the voluntary nature of participation; the hypothetical nature of the assessment; subsequent changes to assessment criteria; and a sample that was unlikely to be representative of new PIP claims. It is now clear that the results were biased rather than merely uncertain.”

Among the excuses, the OBR notes that the forecasts are subject to changes in the composition of the population which is making claims, legal challenges about the scope of the benefit, and changes in the way that benefits are delivered.

Oh, my: who’d have thought it?  Well, as it happens, I did.  I wrote in this blog on 15th December 2012:

I think the predictions are likely to be wrong. The common experience of selective benefits has been that when governments try to impose firmer boundaries, they are liable to discover that needs are deeper, more complex and more difficult to reject than they imagine. The distinction between the lower and middle care rates on DLA has always been confusing, and many people can argue persuasively for higher banding. There are new opportunities to include people with psychiatric disorders. And the PIP rules do not exclude the growing numbers of older people claiming DLA. Short term reductions have to be offset against the general trend, and as time goes on, inexorably, there will be pressure to extend protection. That happened with Single Payments, it happened with Incapacity Benefit, it has happened with DLA, and it will probably happen here, too.

 

A glimmer of hope for disability benefits?

I’ve just spent a productive afternoon at a round-table discussion of benefits for disability, at the Scottish Parliament.  While many groups are understandably concerned with the transition from UK to Scottish administration, there is also some interest on seizing on the opportunities that the new legislative framework offers.  The need to protect people’s current situation is however emphasised by a recent report from the MS Society, charting the impact that the transition from DLA to PIP has had on people with multiple sclerosis.  The transition had had a major negative effect on daily life, emotional well being and the medical condition of sufferers.

There’s a limit to what the Scottish Government can hope to do; the system is a mess, and resources to revive it are limited.  The best hope probably lies in reforming the culture of the administration:  moving, if it can be done, from an adversarial system to one that listens, learns and corrects its mistakes.

Confusion about PIP

There’s a report in the i this morning about a letter sent by Frank Field MP to David Gauke, the Work and Pensions Secretary, detailing some of the hardship and problems  that have been created in the benefits system.  Field calls for a thoroughgoing review of current benefits, which I’d fully support.  But one of the points in the article is a mistake, almost certainly made by the newspaper reporter:

He backed an urgent review of the assessment system for evaluating PIP claims amid frequent complaints that it was too rigid to assess accurately claimants’ ability to work.

Presumably this is meant to refer to the assessment for Employment and Support Allowance.  Personal Independence Payment, unlike ESA, is not an out-of-work benefit; it’s a general income supplement for people with serious disabilities, supposedly partly intended to cover extra costs, and it is paid regardless of whether or not the person is working or able to work.    But I have come across cases, and I’m sure that Frank Field will have done as well, where PIP assessors have wrongly and inappropriately been asking people about work.  It’s the wrong test for this particular benefit.

From DWP research, many people never understood what they were claiming when they applied for  Disability Living Allowance, and now it’s being replaced by PIP it’s probably true that they don’t really understand that either.  Part of a review should be an attempt to get benefits that make sense to the people who administer them and to the people who get them.

 

A ministerial announcement on the next devolved benefits

Angela Constance, the Cabinet Secretary for Communities, Social Security and Equalities, made a statement yesterday about the first changes to benefits reflecting the shift in powers in the Scotland Act.  The new schemes for maternity (the “Best Start” scheme) and for funeral payments will come on line in 2019; although the application process will be “simplified”, they will continue to be one-off, means-tested payments.

Carers Allowance will be the first new benefit to come on line, starting in Summer 2018.  The purpose of the benefit is to bring up the rate of Carers Allowance (currently £62.70 pw) to equal the rate of Jobseekers’ Allowance (£73.10 pw for those over 25).  Rather than taking over Carers Allowance, the Scottish Government has opted to pay a supplement to the DWP-administered  benefit. It will be done by making two payments a year, and while the payment will be made by the new Scottish Social Security Agency, it depends on information drawn from the systems and processes of the DWP.

Transferring responsibility from the DWP to the new agency would have been complex task; that has been avoided.  Paying a supplement weekly or monthly would involve constantly passing information back and forth; that has been avoided, too.  However, the decision will have some substantive implications.  Currently Carers Allowance is not actually paid to many people who are nominally entitled; that will still be true.  Claiming Carers Allowance may have negative effects on a disabled person’s entitlement to the severe disability premium; that will still be true.  There had been talk of extending the benefit to younger people or those in full time education; it looks like that is not going to happen. So, for the while at least, the decision is going to lock the basis of payment a little more firmly to the status quo.

Reforming PIP

The Government’s proposals for the reform of PIP make for curious reading.  The DWP press release explains that the purpose of the proposals “is to restore the original intention of the benefit which has been expanded by the legal judgments.”  The fullest account of the rationale for the policy is however given in the Equality Analysis, which covers the detailed arguments without saying much about equalities.

The problem that the proposals are supposedly addressing is that a couple of legal decisions have accepted that people with a range of disabilities might reasonably be said to qualify for support under the rules as passed.  Those disabilities mainly relate to people who have to manage a medical condition or therapy, which is expressly provided for in they regulations, and people who suffer from mental disorders that interfere with their capacity to travel.   The responsible minister has explained that

The Government continually monitors the effectiveness of PIP to ensure it is delivering its original policy intent and supporting those who face the greatest barriers to leading independent lives. Two recent Upper Tribunal judgments have broadened the way the PIP assessment criteria should be interpreted, going beyond the original intention.

The Equality Analysis goes into more detail about the apparent intention.

PIP is a payment that is intended to be broadly proportionate to the overall need of a claimant. The greater someone’s need, all else being equal, the greater the cost they will face as they go about their daily lives.

The analysis argues that  the tribunals’ interpretations of the points schemes go further than the DWP intended.

There are three problems with this account.  The first is the question of what PIP is supposed to be about.  If PIP is really supposed to be an extra cost benefit, it makes little sense to offer it without reference to people’s ability to pay.  The truth is that when the non-means tested benefits were introduced, they had a very different objective.  The Disablement Income Group had been campaigning for a recognition that the incomes of people with disabilities were consistently lower than for others.  Alf Morris explained, in Parliament (10th and 15th Jul, 1970):

“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.”

The point of the non-means tested benefits was to introduce a   general income supplement, recognising that the incomes of people with disabilities were consistently lower than for others.

The second problem lies in using an assessment of functional activity as the basis of an assessment of costs.  This makes no sense – and the Equality Analysis explicitly acknowledges that it doesn’t work.  Testing people’s activities is “a proxy for their overall need”, but then it goes to explain that assessing costs is not practical:  “it would not only lead to inconsistent outcomes but would also be expensive and difficult to administer.”  If there was a direct relationship between need and cost, this would not be true – and the outcomes wouldn’t be inconsistent.  As far as I can tell, there isn’t such a relationship, or at least not one at the level there would need to be to make it the basis of an individual assessment.

The third problem concerns the Government’s intention.  It’s clear that the Government thought that introducing PIP would save money, and that the benefit would be more restrictive than the Disability Living Allowance.  I challenged that assumption more than four years ago, when I wrote this:

the target is a reduction of 600,000 people taken off benefit by 2018. I am not sure how a cut in numbers of that size is supposed to be achieved, but it is most probably made up of three elements: people who will lose the lower rate for the care component, people who fail to turn up for assessment, and people whose conditions have improved sufficiently not to qualify. (There is a fourth element, which is the attempt to individualise assessments more closely – blind people, for example, will no longer qualify automatically for higher rate mobility – but that can work both ways.)

On general principles, I think the predictions are likely to be wrong. The common experience of selective benefits has been that when governments try to impose firmer boundaries, they are liable to discover that needs are deeper, more complex and more difficult to reject than they imagine. The distinction between the lower and middle care rates on DLA has always been confusing, and many people can argue persuasively for higher banding. There are new opportunities to include people with psychiatric disorders. And the PIP rules do not exclude the growing numbers of older people claiming DLA.  Short term reductions have to be offset against the general trend, and as time goes on, inexorably, there will be pressure to extend protection. That happened with Single Payments, it happened with Incapacity Benefit, it has happened with DLA, and it will probably happen here, too.

And so it has proved.

The IEA fails to understand some basic facts about disability

The Institute of Economic Affairs has published a briefing on Disability Benefits.   They claim that the cost of disability benefits could be reduced by making sure that more people with disabilities went into work.  The approach has been sympathetically reported in the Mail and the Independent.  Unfortunately, the briefing is written with a cavalier disregard for the most basic facts about disability benefits, which rather tends to undermine any arguments they wish to make about what should be done.

There are three quite simple reasons why a greater emphasis on work will not do very much.

First, disability benefits are mainly provided for people who are not part of the labour market.  Half the population with disabilities consists of elderly people (the figures used to show more than half; the 2011 census puts it at 48%).   Claims for Attendance Allowance, and a third of the claims for Disability Living Allowance, are made by older people.

Second, disability benefits are provided for many reasons which have nothing to do with work – among them meeting special needs like mobility, supporting care,  compensation for injury and even (in War Pensions)  reward for merit.  The main justification for DLA is not really to cover extra costs, as many suppose, but to compensate for long-term low incomes of people with disabilities.   None of these reasons disappears if people are in work.

Third, and following from that, many disability benefits (such as DLA and PIP) are provided regardless of people’s income or employment status.  The main benefit supporting disabilities for people of working age who are not in work is Employment and Support Allowance – and while it is true that ESA has been used to cover a hotchpotch of different circumstances, sometimes including disability, it is a sickness benefit, not a disability benefit.  Disability is neither a necessary or sufficient reason for getting it.

It’s true that the numbers of ESA claimants have persistently failed to go down, unless it is by the rather brutal approach of using disentitlement and sanctions to throw people off benefits with no income.  The main reasons why so little has been achieved for ESA claimants  are

  • the failure of psychiatric services to achieve valuable outcomes for people with long-term mental illness
  • the use of ESA as the low-income equivalent of schemes for early retirement
  • the preference of employers for employees who do not have long-term limiting health conditions
  • the penal treatment in the benefit system of part-time and therapeutic work, and
  • the perverse emphasis on individual effort to find a job, mainly focused on people who are too ill to work.

If what the IEA is saying is that more people on ESA need to work, they have about 25 years of policy failures to show that policies which try to do this are ineffective.

 

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.