Incapacity Benefit reform and mental health

Joe McCusker, Policy and Advice Manager at Rethink, argues that the proposed reform of Incapacity Benefit may have adverse effects on people with mental health problems unless government puts in place programmes to address the stigma of mental health in the labour market and an adequate safety net for those who are unable to work.

In October 2006, the long-awaited Welfare Reform Bill went into Committee stage for consideration of the details of the proposals. Reform of Incapacity Benefit (IB) lies at the heart of the proposed legislation. The overarching aim is to reduce the number of people on incapacity benefits by one million. This is to be achieved by targeting people locked into long-term dependency on IB to return to work. Chief among them are people with mental health problems who make up over a third of people claiming Incapacity Benefit.

Changes to Incapacity Benefit

Set to be introduced in November 2008, the main provisions of the Bill are to:

• abolish IB and Income Support (IS) for incapacity for work for new claimants and replace them with a single Employment and Support Allowance (ESA);
• redesign the Personal Capability Assessment Test (PCA) with a completely new mental health test which will become an assessment of ‘mental, cognitive and intellectual function’ that focuses on capability to work and not just entitlement to benefit;
• extend the Pathways to Work pilot schemes for IB claimants and roll out across the UK with voluntary sector organisations invited to manage the Pathways programme;
• introduce compulsory and more frequent work-focused interviews and extend these to more groups of people.

Employment Support Allowance

The ESA will, for the time being, only apply to people making new claims from November 2008. Its main features are:

• an integrated contributory and income related allowance which will consist of an initial allowance set at basic Jobseekers Allowance (JSA) levels, followed by an additional Employment Support component if the new PCA is satisfied;
• entitlement to the Employment Support component, in most cases conditional on meeting compulsory work-focused interviews and work-related activity. Only those with the most severe disabilities and conditions will be exempt from this condition. This will not be determined by reference to specific condition or disability but identified through the new PCA test;
• no additional amounts for dependants or age-related payments.

The ESA will therefore operate as a dual benefit. Those considered to be the most severely ill or disabled will receive the support allowance which will be higher than current IB rates, with no conditions attached. Those seeking to get back into paid work will receive the employment-related allowance at JSA levels. Younger people under the ages of eighteen and 25 claiming the new ESA will receive a lower rate of benefit than those under eighteen and 25 currently in receipt IB.

Personal Capability Assessment test

The Department for Work and Pensions (DWP) review of the PCA test involves a completely redesigned mental health test based on ‘cognitive’ and ‘intellectual’ function. The test, guaranteed to take place within three months of an initial claim for ESA, will be structured in a similar way to the existing physical test, with fifteen areas of mental function each containing various descriptors, and a score of 15 (as opposed to 10 under the current test) being required in order to pass the test. The current provision to combine physical and mental health scores together to reach a score of 15 will be removed, as will the physical descriptors that currently score three points.

The new PCA is currently undergoing testing and evaluation to see if it represents a fairer, more robust and accurate assessment of entitlement. It is expected that this will continue well into 2007 with a view to being ready for the implementation of the Bill. The PCA review is available at www.dwp.gov.uk/welfarereform/tpca.pdf.

Pathways to Work

The Pathways to Work scheme for IB claimants is due to be rolled out across the UK. The scheme combines more contact with Jobs and Benefits Personal Advisers, promotion of existing Jobs and Benefits services like the Disability Employment Advisers and access to new services such as Condition Management, work preparation, an adviser discretionary fund, in-work support, and a £40 per week Return to Work Credit payable for one year. Pathways will replace the current Jobs and Benefit scheme and will apply to new ESA claimants. A person making a new claim for ESA on or after November 2008 will be required to:

• attend a first work-focused interview eight weeks after the claim and five further monthly work-focused interviews;
• prepare and update work action plans as part of the interviews.

Existing IB claimants will not have to create action plans but will be able to access the new support available.

If a person fails to attend a work-focused interview without evidencing ‘good cause’, benefit could be reduced and in some cases stopped. In most cases, a person has just five working days to tell her/his Personal Adviser the reasons for failing to attend the interview before benefit sanctions apply.

IB reform and mental health

There is no doubt that the current structure of IB is failing many people with mental illness who wish to do some work but lack the support necessary to do so. However, there are concerns that the proposals do not go far enough in providing a real opportunity to improve the lives of the thousands of people with mental illness currently receiving IB who want to work; or in giving adequate support for those who are unable to work due to their health.

Operating as a two-tiered benefit, the ESA is inherently flawed and ignores the dynamic nature of mental illness. It is difficult to see how a clear division can be made between people with ‘more severe’ and ‘less severe’ mental health conditions. The current PCA test is a bad indicator of severity of mental health and it appears that the new test, with its focus on capability to work, will not address this. The proposal for a medical assessment to take place within the first twelve weeks of a new claim seems unrealistic for mental health conditions. People with mental illness frequently find that their diagnosis changes, particularly in the first stages and months of illness.

The ESA also fails to take into account that many people with mental illness have fluctuating symptoms and may need to move between the two tiers of the new benefit at different times. It is difficult to see how an immediate movement between the two tiers could be easily achieved with the administrative delays that typically occurs with any changes to benefit entitlement.

As with the current test, there is a concern that the revised mental health descriptors and points awarded in the new test will not be given sufficient weight in assessing the capability to work of a person with mental health difficulties. For instance, under the current test many of the mental health descriptors are only awarded one or two points, yet many of the symptoms (eg preferring to be left alone for six hours or more each day) would severely impact upon a person’s ability to work.

There is a further concern regarding the lack of knowledge of mental illness among PCA medical assessors. This was illustrated when, in a recent IB appeal case in Northern Ireland, the Rethink representative found that only after the first three questions on the medical assessment, the medical assessor stated that ‘the claimant did not suffer from severe mental illness’, despite the fact that the person had been attending a psychiatrist for many years, was expected to do so for many years to come and was being treated with a high dosage of anti-psychotic medication. It is important that people with mental illness and mental health professionals are involved in the design of the new PCA to ensure the fairness and accuracy of the new mental health descriptors in their application on a person’s ability to work, while also ensuring that claimants are not subject to unnecessary compulsion and conditions which could indeed add further to their mental illness related stress and anxiety. Leading on from this, exemptions from the PCA on mental health grounds need wider elaboration by the DWP as the current definition of ‘severe mental illness’ used for exemption is too narrow.

While the financial incentives of the Pathways Programme and other help to undertake employment (return to work credit, discretionary payments and Condition Management), are welcome, there are concerns around the built-in mechanisms of compulsion and sanctions of the programme.

The relationship between the individual and the ‘Pathways Personal Adviser’ is critical as it will be the Personal Adviser who will assess job suitability and agree work-related plans, make decisions to reduce or stop benefit for failure to attend interview, and decide what support and assistance a person needs to return to work. Government has not announced any measures or additional resources to train Jobs and Benefits Personal Advisers.

Without any real knowledge or understanding of mental illness and the symptoms, this could lead to unsuitable job opportunities, unrealistic work-related activities and unnecessary sanctions being imposed. For instance, how would a Personal Adviser know enough about mental illness to make a judgement about whether someone is failing to attend a work-related interview for no good reason, or because of a deterioration in mental health? Would people face benefit sanctions if they stopped their medication because of severe side effects, or stopped their medical treatment to try complementary therapy? Would their benefit be sanctioned if they feel that they are not ready to return to work because they believe that it will have an adverse impact on their mental health?

Without adequate training and understanding of mental illness, compulsion and sanctions may only serve to alienate those who are not ready for work and focus their attention on regaining benefit rather than motivating them to gain employment. The legislation does allow for involvement of the voluntary sector in the management of Pathways but the extent of non-state agencies involvement in the decision-making processes of the programme is unclear.

Underpinning the government’s Welfare Reform Bill is the idea that the vast majority of people on IB can and should be able to work rather than having an existence of long term dependency on benefits with no employment support opportunities. However, the Bill fails to take into account the barriers (such as loss of benefits, lack of suitable jobs, apathy and fear of the tax credit system) preventing many people with mental illness from returning to work. The main barrier is stigma and widespread discrimination in the labour market and in the workplace. Research carried out in Britain found that less than 40% of employers said they would employ someone with mental illness, while 75% said that employing someone with schizophrenia would be impossible or very difficult. The government’s plans fail to recognise the high levels of employer discrimination towards people with mental illness who want to return to work. The Work and Pensions Select Committee described the government’s current initiatives with employers as ‘wholly inadequate’. There is no point in pushing people with mental illness towards work if employers are prejudiced against giving them jobs in the first place. The reforms would be greatly strengthened by government action to end the prejudice, ignorance and fear that surround the labour market discrimination of people with mental illness.

Conclusion

The new ESA will be based on the premise - albeit with some limited exceptions - that it is a benefit for people seeking work rather than an income replacement for people who become sick or unable to work. Many of the people whom the reforms are to be targeted at are the hardest to reach and most vulnerable in society. The Pathways programme, if given adequate resources, may be a step in the right direction as some claimants will welcome the extra support, but attaching compulsion and conditions is not necessary to achieve positive outcomes, while sanctions run the risk of further alienating those who are hardest to reach.

The Bill and its plans to radically overhaul IB are an opportunity to create a benefit system which promotes employment opportunities for people with mental illness, allay their fears about loss of benefits, and guarantee a decent level of income when they feel unable to work. Unless government takes action to put in place a programme dedicated to reducing the stigma of mental illness and providing an adequate safety net of financial support, it could result in lost opportunities for those with mental illness currently claiming IB and for those claiming the new ESA to undertake work, while at the same time pushing those unable to work deeper into poverty.