Wednesday, 18 November 2015

Work Capability Assessment undermining mental health

Since 2010 the Work Capability Assessment (WCA), has been used to assess the eligibility of claimants for out of work disability benefit.  In introducing WCA the government claimed it was a measure to get more people back into the workplace and help curb the government’s rising welfare bill, with the implication that many of those on benefits were 'shirkers'.  It was all part of the government's political narrative of 'workers' versus 'shirkers'.

The government were warned by health professionals that the harsher assessments would have major impact on mental health.

At the outset there were problems with the way fitness to work was being made and doubts that those making the assessments would have the necessary expertise and experience to make an assessment of how any particular mental condition impacts on the life of the claimant.

Doctors and disability rights organisations have long voiced fears that use of the tough new criteria to measure incapacity to work is undermining the mental health of claimants.  These concerns were voiced in this blog in an article published two years ago. However, up till now, there has been no hard evidence to substantiate these concerns.

Now new evidence published in the Journal of Epidemiology and Community Health confirms that the introduction of the more stringent test to assess eligibility for disability benefit in England may have taken a “serious” toll on mental health.

Areas with the greatest use of the WCA in assessing existing claimants have seen the sharpest rises in reported suicides, mental health issues, and antidepressant prescribing, the findings show, prompting the researchers to question the wisdom of introducing this policy.

To find out if there was any link between use of the WCA and a rise in the prevalence of mental health issues, the researchers analysed the numbers of disability assessments carried out in 149 local authorities in England between 2004 and 2013.

They looked at local trends in suicide rates among 18 to 64 year olds; antidepressant prescribing patterns; and Labour Force Survey data on self-reported mental health issues among the working population in each local authority.

Between 2010 and 2013, more than one million people claiming disability benefit were reassessed using the WCA.  Furthermore, a higher proportion of people living in areas of deprivation were reassessed, putting added pressure of people already struggling.  The findings of the study are stark.

In areas with higher rates of reassessment, there was a corresponding increase in suicides, mental health issues, and antidepressant prescribing.

After taking account of the impact of baseline deprivation, economic trends, and long term trends in mental health, the researchers calculated that, there were around six extra suicides, 2700 more cases of mental ill health, and an extra 7020 prescriptions for individual antidepressants for every 10,000 people reassessed during this period.

This adds up to a total of 590 additional suicides, 279,000 extra cases of mental ill health and 725,000 more prescriptions for antidepressants across the country as a whole that were associated with the reassessment policy between 2010 and 2013.

This is an observational study, so no firm conclusions can be drawn about cause and effect. None the less, the researchers point out that they were at pains to adjust for other potentially influential factors, and that the observed increases in mental ill health followed—rather than preceded—the reassessment process.

The findings have important implications for the WCA policy particularly as this was introduced without any evidence of its potential impact or any plans to evaluate its effects. A further 1 million people will have been reassessed this year.

As I have repeatedly argued in this blog, the policy raises ethical issues for the doctors involved, given that they have professional and statutory duties to protect the health of patients and the public.  The authors say their study provides evidence  that the policy in England of reassessing the eligibility of disability benefit recipients using the WCA may have unintended but serious consequences for population mental health, and there is a danger that these adverse effects outweigh any benefits that may or may not arise from moving people off disability benefits.

“Although the explicit aim of welfare reform in the UK is to reduce ‘dependency,’ it is likely that targeting the people living in the most vulnerable conditions with policies that are harmful to health, will further marginalise already excluded groups, reducing, rather than increasing, their independence,” they conclude.

Peoples' lives are a narrative. They are not disjointed bits of data. Disability isn't simply a problem confined to the individual as a physical being but also as a social being. The social condition can have as much of an impact as any measure of 'disability'; circumstances can be disabling. How any particular condition affects a person's capabilities may vary with time, with geography and with other physical or mental conditions. In short the way in which any condition can be disabling is complex. Sometimes it is the very complexity that is disabling. Disabilities are most often multifaceted.

The government chose to ignore concerns that assessment was being made by inexperienced staff and that such assessments would have major impact on the mental health of claimants. 

In evidence presented jointly to the 3rd yearly review of WCA mental health organisations had said:

“We believe that, without expertise in the causal conditions, healthcare professionals are not sufficiently equipped to understand why and how function may be impaired or to elicit the relevant information from an applicant who may have… difficulties in reporting their condition” (joint response from the Centre for Mental Health, HAFAL, the Mental Health Foundation, Mind, Rethink Mental Illness, the Royal College of Psychiatrists and SAMH )

This new evidence supports the contention that tougher disability benefit assessment is taking a “serious” toll on mental health with higher reassessment rate being linked to more suicides, mental ill health, and antidepressant use. 


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