The Work, Health and Disability Green Paper

“To own the discourse is to win the argument”

The Green Paper on Work, Health and Disability  was published online late afternoon of Monday 31st October.  The DWP had been briefing since the Saturday before, that a major reform was proposed to the Work Capability Assessment and that all the evidence was that work is good for people’s health.

Newspapers and television news highlighted the proposals but no-one actually saw the document until news media had been running the DWP storyline for almost 48 hours  The BBC initially intended to film some interviews at a London disabled people’s organisation on Monday afternoon but cancelled it as by then the story was no longer news.

The consultation on the Green Paper is running until 17th February, long enough for individuals and organisations to get to grips with what is really being proposed.

I’ve focussed in this blogpost on three important contentions made in the Green Paper, on which some of its proposals are based.  I’ve tried to get behind the spin which accompanied its launch to see what exactly is being proposed.

The Green Paper opens with the statement that “The evidence that appropriate work can bring health and wellbeing benefits is widely recognised”. The reference for this is the major review of evidence, published by the DWP in 2006.

On the face of it, this is a fairly uncontentious statement.  The word ‘appropriate’ recognises that not all work has a positive impact and the phrase ‘can bring’ indicates that this is not a claim of a unilinear causal relationship.  Indeed, early on in the Green Paper the complexities of the relationship are acknowledged:

…….whilst work is good for health in most circumstances, the type of work matters. Many factors such as autonomy, an appropriate workload and supportive management are important for promoting health at work.

This reflects the conclusions of the 2006 review.  The Green Paper could also have drawn on more recent longitudinal research from Australia which found that low paid, insecure jobs, characterised by a lack of control, were associated with poorer health than that found amongst those people who remained out of work.

Getting a high quality job after being unemployed improved mental health by an average of 3 points, but getting a poor quality job was more detrimental to mental health than remaining unemployed, showing up as a loss of 5.6 points.

This is an important finding, particularly bearing in mind the conclusion of the DWP’s 2006 literature review that: “After leaving benefits, many claimants go into poorly paid or low quality jobs, and insecure, unstable or unsustained employment. Many go on to further periods of unemployment or sickness, and further spell(s) on the same or other social security benefits”.

Unfortunately, the tone of the rest of the paper and its proposals assume a straightforward unilinear relationship between being in paid employment and good health, as illustrated by what the DWP calls an ‘infographic’ on page 4 of the Green Paper.  This shows two circular relationships, good health and work on the one hand and worklessness and poor health on the other.

The Green Paper would have been more accurate if it had concluded that, while paid employment can increase your standard of living, social interaction and self-esteem, it can also be bad for your health and can create or worsen illness or impairment. Whether work is good for your health will depend on your state of health and the nature of the job. As, according to the DWP’s own evidence, people leaving benefits often go into poor quality jobs, they are less likely than the average person to find that paid employment has a good impact on their health.

The payment of out of work benefits has always been conditional but since 2010 the conditions have increased and withdrawal or reduction of payment can now last from four weeks to three years.The assumption is that this threat of, or the actual experience of, withholding income will make it more likely that a person will take steps that increase entry into employment.

The recent decision to reduce, by almost £30pw, the money paid to people who have been assessed as being unfit to work but able to take on work related activity (the ESA Work related activity group) is based on the same assumption: the DWP claimed it will “remove the financial incentives that would otherwise discourage claimants from taking steps back to work”.

In an earlier blogpost I examined the evidence that DWP relied on to make this claim.  It’s worth reiterating that there is no evidence of a causal relationship between a reduction in benefit levels and an increase in employment amongst disabled and sick people.

There is, in fact, a more convincing case to be made that reducing or withdrawing income will make people less able to gain employment. An evaluation of the impact of benefit reduction found that the more benefit was removed the less likely they were to move into employment.  A study which carried out four ‘natural’ experiments in the US and in India concluded that poverty undermined people’s ability to think clearly, carry out tasks and to make good decisions (a conclusion which is perhaps obvious to anyone who has experienced the pressures that come with even short-term financial difficulties):

The poor must manage sporadic income, juggle expenses, and make difficult tradeoffs. Even when not actually making a financial decision, these preoccupations can be present and distracting. The human cognitive system has limited capacity. Preoccupations with pressing budgetary concerns leave fewer cognitive resources available to guide choice and action.

The widely disseminated conclusion from this study was that, because people living in poverty expend more of their mental capacity on managing with a low income, government programmes aimed at helping them should not impose what some called a ‘cognitive tax’ – such as complicated forms, frequent monitoring systems, onerous requirements to prove eligibility.  As the Behavioural Insights Team argue:

“The worries involved in making ends meet every day already deplete [cognitive] bandwidth so government services aiming to tackle disadvantage – such as savings schemes, employment advice and parenting programmes – should be required to pass a cognitive load test to ensure these services do not make it harder for people on low incomes to make good decisions for themselves.”

The Behavioural Insights Team is an organisation originally set up by the government (the ‘Nudge Unit’) and still partly owned by them. This study was carried out in partnership with the Cabinet Office.  We would normally expect their conclusions to be treated seriously but that does not appear to be the case in this instance.

The Green Paper indicates an intention to reduce the numbers of people in the ESA Support Group. These are people who have been assessed as having limited capability for employment and also limited capability for work-related activity – meaning that they are exempt from complying with requirements to take ‘steps back to work’.  Concern that there are ‘too many’ people claiming this type of benefit dates back to the 1990s when Invalidity Benefit was replaced by Incapacity Benefit.   A series of changes since then in the method and process of assessment have not had the desired effect of reducing numbers qualifying for long term sickness and disability benefit.

The Green Paper proposes yet another change in the assessment regime and an extension of ‘employment support’ to people who have been assessed as not able to either work or to engage in work-related activity.  Instead of one assessment (the Work Capability Assessment) there would be two: the WCA would assess financial entitlement and then everyone on ESA, whether in the Support Group or not, would be subject to a “separate process” which would decide whether “someone should engage with Jobcentre Plus or specialist programmes”.

People would be required to have continuing contact with a ‘Work Coach’ who: could have full discretion to tailor any employment support to each individual claimant. This approach would be truly responsive, allowing the work coach to adjust requirements and goals dependent on changes in a person’s condition or circumstances.

While Damien Green previously announced that those in the Support Group would not have to undergo repeated WCA assessment, this new system could potentially require repeated and continuing ‘discretionary’ assessment by a work coach as to what a person should be required to do.

So let’s look at whether there is any evidence that the ‘support’ to be offered by this new system is likely to increase employment amongst disabled people or people with long-term health conditions.

The first thing to point out is that the assumption underpinning the Green Paper’s proposals is that people who are unfortunate enough to experience ill health and/or disability and unemployment are not capable of – or are not to be trusted to – make decisions in their own best interests.  Instead it is the role of a State employee or contractor to do this.

So the Paper proposes that “trained work coaches could have discretion to make case-by-case decisions about the type of employment support a person is able to engage with” (para 132).

The second thing is that anyone entering this system gives up all right to privacy about personal information held on them by the “NHS, the adult social care system or through other benefit applications, such as from a Personal Independence Payment application” as the assessment for financial support (the current WCA) and the work coach would draw on these sources of information (para 135).

A third point is that the employment support programmes have not in the past been very successful at helping people on long-term out of work sickness/disability benefits to find and retain paid employment.  Only 12.5% of ESA new claimants on the Work Programme get a job outcome within two years. The equivalent figure for people moving onto ESA from Incapacity Benefit is 4.7%.  Work Choice, the specialist programme aimed at disabled people has a higher rate of success but less than 1 in 5 of participants are on ESA with the majority being on Job Seekers Allowance, so the programme has not proved its effectiveness with people on ESA.

As the government has previously announced, the Work Programme and Work Choice are being discontinued and replaced with a new Work and Health Programme.  However, this will only have 20% of the funding previously invested in employment support.

The Green Paper also proposes that the:

“earlier engagement between an individual and a work coach in Universal Credit will also serve as a gateway to a wider, integrated system of support offered by the Department for Work and Pensions and other agencies, such as the NHS and local authorities”. (Para 84)

This “wider, integrated system of support’ is called Universal Support and is intended to “assist people with their financial and digital capacity throughout the life of their claim”.

“Through Universal Support we are transforming the way Job centres work as part of their local communities to ensure they more effectively tackle the complex needs some people have and support them into sustainable employment”. (Para 85)

Unfortunately, this transformation is not borne out by the DWP’s own evaluation of Universal Support in the trial areas.  The evaluation, published in July this year, concluded:

“the results suggest that participation in USdl had no statistically significant impact on either digital or financial capability…..Overall, the estimated annualised cost of the eleven trials was just over £4 million. Staff costs made up £2.7 million of the total.”

So £4 million was spent with no resulting improvement in claimants’ ability to engage with the UC system or with managing their finances. (Incidentally, the Green Paper also holds up the Troubled Families programme as ‘another example of an integrated approach’.  It’s surprising that they infer that this programme makes any difference as the evaluation published recently “was unable to find consistent evidence that the programme had any significant or systematic impact”)

It is unlikely therefore that there will be sufficient assistance available through the specialist employment support programme.  And Universal Support is unlikely to be of much assistance in terms of helping people to navigate the complexities of the system. So what will be offered to people in the Support Group as part of the ‘claimant commitment’?  The Green Paper does not spell this out explicitly but it would seem that the intention is that Work and Health coaches will decide what kind of health-related intervention someone needs.

How long before part of the ‘claimant commitment’ includes a requirement to participate in a ‘health intervention’ of some kind and sanctions are attached to non-compliance?

It isn’t really employment support that is on offer – rather we are on the road to a situation where people who are too ill or disabled to work are required to subject themselves to health interventions that an employee (or contractor) of the DWP decides is good for them.

It’s important that responses to the Green Paper home in on what is actually being proposed, rather than merely respond to the questions posed by the DWP.  The proposed changes are merely the latest in a long line of attempts to reduce the numbers of people qualifying for long-term out of work sickness/disability benefits.  If the assumptions on which the proposals are based are not backed up by evidence then they will be unlikely to have any more impact on reducing the disability employment gap than their predecessors.

Magical thinking refers to the false attribution of causal relationships. In the context of psychology it refers specifically to the belief that one’s thoughts by themselves can bring something about – or that thinking something is the same as doing it.

Not only does this Green Paper ascribe a fallacious unilinear causal relationship between work and health, but it replicates a common feature of government policy – the assumption that saying something will happen makes it happen.

This is the fourth time in my engagement with social policy that a government has complained about the number of people ‘languishing’ on long term out of work benefits.  The fourth time that proposals are made which will supposedly reduce these numbers.  Any bets on how soon we will see a fifth?

First published on Jenny’s blog