Does the emergency handbrake hold up?
The Tony Blair Institute's proposals to cut disability benefits don't stack up, even on their own terms
Earlier today the Tony Blair Institute released a paper on reforming the social security system for disabled people. The central proposal of the paper is what the authors describe as a ‘handbrake’ to reverse the trend of increasing spend on disability-related social security:
The government should introduce a category of non-work-limiting conditions. These are conditions where the default assumption is that the condition is compatible with work – and therefore does not attract out-of-work benefits or require additional cash support through PIP. This list would be regularly updated with each condition supported by evidence of its impact on work.
There’s a lot to say about the wider context. As Professor Ben Baumberg Geiger pointed out last year, recent claims about ‘out of control’ social security spending are overblown. The picture is more complex, with a genuine rise in disability-related claims offset by historic cuts and freezes to other parts of the system. Others including Tom Pollard at Mind have written about the principles that underpin these proposals:
Declaring some conditions 'non work-limiting' is a discriminatory & simplistic response to a hugely complex challenge. People with the same diagnosis have very different experiences of the impact on their ability to work, often based on wider circumstances. The fact that good work can be good for you is no basis to claim that specific conditions are 'non work-limiting', as the report suggests.
But I think it’s also likely that these proposals don’t quite stack up even on their own terms.
Relying on medical evidence
The report suggests the DWP work with independent experts to build ‘functional profiles’ of different conditions that are unlikely to limit a person’s ability to work or to live independently. In the authors’ view these include ‘mild to moderate’ depression and anxiety disorders, as well as common musculoskeletal problems.
The idea would be that people with these conditions applying for PIP or the health element of Universal Credit would score zero by default, unless they could demonstrate that the way the presentation affects them is ‘atypical’.
On that last point, I want to quote the authors directly. Because I think it’s central to how viable the proposal is:
Those able to prove they have an atypical presentation – for example through a secondary care note or formal occupational-health assessment – would be able to overturn the presumption at assessment or challenge it at appeal. This would ensure the system remains responsive to individual circumstances.
The report doesn’t go into detail about what criteria would be used to determine whether someone has an ‘atypical presentation’, though it is clear that this would need to be substantiated with medical evidence, likely from secondary care services.
This leaves, I think, a two-stage test:
Does the person have medical evidence in the specified form?
Does the person meet the standard functional criteria for PIP or UC health?
The problem is how much heavy lifting this leaves to the medical evidence.
When I worked in mental health services, many of my clients had long been discharged from community teams - often when they were too unwell to sustain appointments or engage with professionals.
Many of the people with the most severe mental health problems ended up solely being supported by a GP they trusted or else ‘falling off the grid’ of services altogether. Some had historic medical evidence at home, but were so unwell that it would take repeated home visits to find it. This group includes a significant number of people who have ‘generalised anxiety disorder’ or ‘depression’ listed as the main presenting problem on their GP records.
Even when there is relevant medical evidence, it’s rare for it to be sufficient to avoid the need for self-report and human judgement. Clinical notes might show that a person with depression rarely showers or changes. Those same notes may be completely silent about how that person manages their spending or copes with cooking.
None of this is to discount the need to engage seriously with medical evidence.
The TBI report is right to identify that the DWP regularly seeking GP evidence would be a step forward. The government has already committed to developing a portal to make it easier to share medical evidence electronically. There’s more they could do to make sure that this evidence is used systematically - beyond a quick scan from an assessor ahead of an appointment.
But for some conditions, including mental health problems, it’s impossible to avoid applying a level of human judgement to what the medical evidence can and can’t show. The alternative is to risk arbitrarily cutting off income from people in some of the most challenging circumstances.
The risk of medicalisation
A second challenge for these proposals is the risk of driving people to access inappropriate treatment or diagnoses.
The disability benefits system already contains a level of medicalisation. A person who has left an abusive relationship, a person who has had the course of their life shifted by an unexpected bereavement, and a person who is struggling with complex caring responsibilities, might all struggle to work. They might also be experiencing very significant distress in their daily lives.
To get support from the social security system and to be taken seriously, people are often required to describe their experiences in terms of mental health. As Dr Annie Irvine writes:
Without losing the important ground gained in understanding and awareness of mental health problems, and without for a moment disregarding or disbelieving people’s lived experience of distress, we need a broader conceptualisation of ‘capacity for work’. As things stand, ill health is the only category the benefit system offers people as a way to explain their complex, multifaceted barriers to work.
Pushing the social security system further towards medical diagnosis rather than a rounded functional judgement, risks unintended consequences.
If the gateway to PIP or UC health becomes a set of specific diagnoses then people who are unwell and in very difficult financial circumstances will find that what happens in mental health services becomes even more high stakes.
Precise decisions about diagnoses or PHQ-9 scores might start to have implications for people's ability to stay afloat. That potentially means a transfer of anxiety, mistrust and adversarial dynamics from the DWP to the NHS.
The idea of removing eligibility for people with certain conditions has been in the water for a while now. Aside from important questions of principle, I think proposals like this end up facing the same kinds of risks. Either you remove the capacity for judgement in the system, and risk leaving people very severely affected by their conditions with no means of income, or you introduce a carve out and end up grappling with the same fundamental questions that motivated the design of the system we have now.