Written evidence from the Department of Public Health, Policy and Systems, University of Liverpool, School of Law and Social Justice, University of Liverpool (HAB0055)

 

The Health Inequalities Policy Research Team is a designated World Health Organization Collaborating Centre for Policy Research on Determinants of Health Equity, providing research, evidence synthesis, and guidance to international public health policy.

Summary

Introduction

Disability is defined as a longstanding, substantial physical or mental impairment with negative impact on normal daily activities. According to the Family Resources Survey 19/20, there are an estimated 14.1 million disabled people in the UK, affecting 8% of children, 19% of working age adults, and 46% of pension age adults.

 

There is a significant gap in employment between disabled people and non-disabled; in 2020 the gap in the UK was almost 30%.1 Figure 1 shows that this gap has persistently remained throughout recent decades, and the size of this gap is higher in both men and those with low educational attainment.2

 

Figure 1: The trends in the difference in employment rates between people reporting a health problem limiting the kind of paid work they can do, and the rest of the population - men and women aged between 20 and 59. (Source: UK Labour Force Survey)

Additionally, there are significant additional daily costs associated with disability. These two realities mean the risk of poverty is higher among disabled people. This means the benefits for disabled people (both for those out of work [ESA] and to help with increased daily costs [PIP]) are integral to preventing poverty.

 

Historically, rapid increases in claimant numbers for income replacement disability benefits (figure 2) and the persistent employment gap have resulted in a set of policy responses which aim to reduce claimant numbers, and thus increase employment, through reducing the number of people eligible. The most recent substantial reform was to introduce the Work Capability Assessment (WCA) to assess eligibility for ESA. This new assessment process was introduced in 2008, and in 2010 a major reassessment process was started for those on legacy income replacement disability benefits. This evidence submission will cover three areas:

-          The suitability of health assessments

-          The impacts of reforms on disabled people

-          Other approaches

 

Figure 2: Number of people receiving main income replacement disability benefit 1978 to 2016.

 

Suitability of assessment

Two systematic reviews have examined the evidence for changing eligibility criteria for income replacement disability benefits. One from 2010 examined changes in eligibility criteria in the UK, Canada, Sweden and Norway, finding no consistent evidence that eligibility criteria was significantly associated with employment.3 An updated review from 2020 looked specifically at how policy changes to eligibility criteria changed employment for disabled people in OECD countries.4

 

Figure 3 show the breakdown of studies included in this review. There was no consistent evidence that changes in eligibility affected employment of disabled people; some evidence suggested that expansion of eligibility was associated with reduced employment however much of this evidence was specific to the USA and veterans. No evidence from the UK found restricting eligibility had a significant association with changing employment.

 

Figure 3: Harvest plot for employment outcome after reform, stratified by reform type (expansion or restriction), country, sex and QA score.

             

In 2018, the Equality and Human Rights Commission (EHRC) commissioned researchers from the School of Law and Social Justice to conduct a large-scale qualitative study of the impact of the Legal Aid, Sentencing, and Punishment of Offenders Act (LASPO) on people with legal problems in the areas of employment, family and welfare benefits.5 Evidence from the study suggested that in many cases, unresolved employment law issues were driving participants to seek welfare benefits. More restrictive eligibility for disability benefits therefore made it difficult for participants to address the loss of income resulting from their employment law issue, while not solving the issue that led to the unemployment in the first place.

 

Participants also cast doubt on the suitability of the WCA for correctly assessing their situation, perceiving the denial of benefits as arbitrary and medical assessments as incorrect.6

 

‘It’s as if [the medical assessor has] written about somebody else almost because she’s said things in the report that just simply aren’t true’ (Interview 36)

 

Participants reported that the examinations focused on issues not relevant to their claim, such as questions related to mental health for a claim over a physical disability. They perceived the assessment as unfair or unjust:

 

But when you read the report, it’s all based on their opinions – that’s all it is, it’s just their opinion. It’s got nothing to do with my medical records, nothing to do with the specialists I’ve seen, nothing at all. (Interview 102)

 

Impact of the Work Capability Assessment

The impact of the WCA should consider both the impact on poverty and employment. Figure 4 shows the trend in poverty rates of people out of work with and without disabilities between 1994 and 2014. In 1994, disabled people out of work were less likely to be in poverty than non-disabled people, not including the extra costs associated with disability. During this period, the poverty rate of disabled people out of work increased rapidly, while it remained constant for non-disabled people out of work. This suggests that the reforms may have increased poverty risk amongst disabled people who are out of employment. 

 

A study of the reassessment process found a significant negative impact on mental health outcomes at a local authority level. When an extra 10,000 people were reassessed in an area, there was an additional 6 suicides, 2,700 cases of reported mental health problems, and 7020 antidepressant items were prescribed (figure 5).7  These findings are supported by local qualitative work by the Liverpool Mental Health Consortium. The reforms, and the reassessment process, were found to have a detrimental impact on the mental health of claimants, and negative practical financial implications.8 Another analysis of the Labour Force Survey found that reassessment was not significantly associated with movement from economic inactivity (out of work and not seeking work) into employment, however it was significantly associated with movement from economic inactivity to unemployment (seeking work) for people with mental health problems.9 This suggests a growing number of people with mental health problems on unemployment benefits.

 

Figure 4: Trends in poverty amongst people out of work with and without a disability aged 20 to 59. Poverty defined as household income below 60% of the median income after housing costs. (Source: Family Resource Survey)

 

Evidence from the study conducted on behalf of the EHRC found that changes to the benefits system, including the introduction of the WCA, had a negatively reinforcing relationship with legal aid cuts under LASPO, leading to a cycle of people being unable to access the benefits to which they were entitled.5 In addition to financial problems, this led to mental or physical health problems. The stress of pursuing a benefits claim can aggravate existing conditions. The following participant described his mental health situation while pursuing an ESA appeal and trying to get by on food vouchers:

 

Mentally it’s not been too good, like I’ve said before I’m a self-harmer. That’s what I turn to when I get stressed so I’ve tried to stop myself from doing that as well. Financially I’m not doing that good either. I just get on day-to-day. (Interview 40)

Another participant described the negative impact on her epilepsy of the process to try to reinstate ESA. She was one of several participants in the EHRC study that were very anxious to get a job, as is commonly found in other research and that had expended considerable effort only to meet barriers:6,10

 

Yeah, I’ve been in an interview and then I’ve explained to them what my epilepsy is like and then they’re like, then they mention the health and safety thing and I was like, ‘Yeah but it’s the [Equality] Act 2010, and then I explain that to them and then they’re like, ‘Yeah but you have had your interview now’,[1] and like, they were going to offer me the job until I mentioned my epilepsy. (Interview 85 of EHRC study)

 

Figure 5: Association between the number of people per 100 000 Working age population experiencing a reassessment in each local authority between 2010 and 2013 and the increase in suicides, self-reported mental health problems and antidepressant items prescribed during the same period, adjusted for area deprivation.

 

Other Approaches

This section of the evidence submission will focus on other approaches to address the issue of improving employment opportunities for disabled people. As highlighted in the previous sections, there is little evidence to support the approach of restricting eligibility criteria to income replacement disability benefits (such as ESA) and there are potential harms of such approaches to the mental health and poverty status of disabled people. Therefore, a more holistic approach is required. The below table highlights a typology of approaches to improve employment opportunities for disabled people, split into policies focused on influencing employer behaviour and those focused on influencing the behaviour of individuals with disabilities.11 A systematic review found there was evidence to support the effectiveness of employer focussed policies, however there was limited evaluative studies available.12 

 

Some international approaches to this include:

-          Remuneration for business and wage subsidies to overcome the potential costs of having a disabled employee

-          Preferential access to disabled people of equal skill at interview

-          Support for employers to make reasonable adjustments

-          Responsibility on employers to reintegrate sick workers

-          Public agencies actively seek to employ disabled people

-          Public office which works with employers, government agencies and individuals to improve disability employment through advice, guidance and technical assistance on workplace accommodations

 

 


Table: Typology of policy approaches to improve employment in disabled people.

Adapted from Whitehead et al. 2009

 

Category

Perceived problem

Programme logic

Intervention category

Interventions focused on the employment environment

 

 

A. Employers discriminate against disabled/chronically ill in recruitment and retention of staff

Use legislation either to outlaw discrimination in recruitment and employment or to set employment quotas

1. Anti-discrimination legislation

B. Few appropriate employment opportunities available for the disabled/ chronically ill or employers perceive disabled/chronically ill workers to be less productive.

Increase employment opportunities through job creation or financial incentives to employers to employ disabled and chronically ill

2. Incentives to employers, e.g wage subsidies.

C. Employment and workplace inaccessibility creates significant barriers to employment for disabled/chronically ill

Legislate and/or provide support to improve employment and workplace accessibility

3. Workplace adjustments and return to work planning.

 

Interventions focused on the employment environment and on individuals.

D. Loss of contact with the workplace leads to sick-listed individuals moving into long-term sick/economically inactive category. Poor coordination of services hinders the process.

Require employers and service providers to make provision for planned return to work and cooperation among all actors involved

 

Interventions focused on strengthening individuals

E. Welfare system creates disincentives to moving into employment

Increase motivation to gain employment through provision of financial incentives to disabled people or reducing generosity of benefits

4. Changes to welfare system

F. Time outside the labour market means loss of skills in locating and obtaining appropriate work

Provide individualised vocational advice and job search assistance

5. Supported employment and job search support

G. Individuals lack appropriate skills, education or training for available work

Improve skills, education and training to increase “employability”

6. Vocational rehabilitation

H. Individual’s health condition creating limitations on ability to perform job

Provide medical rehabilitation and/or health management advice to reduce impairment

7. Condition management and medical rehabilitation

8. Psychological therapies

Conclusion

 

References

1.               Powell A. Disabled people in employment. London: House of Commons Library; 2021.

2.               Barr B, McHale P. The Rise and Fall of Income Replacement Disability Benefit Receipt in the United Kingdom. In: The Science and Politics of Work Disability Prevention. New York: Routledge; 2018.

3.               Barr B, Clayton S, Whitehead M, Thielen K, Burström B, Nylén L, et al. To what extent have relaxed eligibility requirements and increased generosity of disability benefits acted as disincentives for employment? A systematic review of evidence from countries with well-developed welfare systems. J Epidemiol Community Health. 2010 Dec 1;64(12):1106–14.

4.               McHale P, Pennington A, Mustard C, Mahood Q, Andersen I, Jensen NK, et al. What is the effect of changing eligibility criteria for disability benefits on employment? A systematic review and meta-analysis of evidence from OECD countries. PLOS ONE. 2020 Dec 1;15(12):e0242976.

5.               Organ J, Sigafoos J. The impacts of LASPO on routes to justice [Internet]. Manchester: Equality and Human Rights Commission; 2018. Available from: https://www.equalityhumanrights.com/sites/default/files/the-impact-of-laspo-on-routes-to-justice-september-2018.pdf

6.               Sigafoos J, Organ J. ‘What about the poor people’s rights?’ The dismantling of social citizenship through access to justice and welfare reform policy. Journal of Law and Society. 2021 Sep 1;48(3):362–85.

7.               Barr B, Taylor-Robinson D, Stuckler D, Loopstra R, Reeves A, Whitehead M. ‘First, do no harm’: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study. J Epidemiol Community Health. 2015 Oct 26;70(4):339.

8.               Liverpool Mental Health Consortium. Austerity, Adversity & Welfare Reform: The Impact in Liverpool. Liverpool: Liverpool Mental Health Consortium; 2017.

9.               Barr B, Taylor-Robinson D, Stuckler D, Loopstra R, Reeves A, Wickham S, et al. Fit-for-work or fit-for-unemployment? Does the reassessment of disability benefit claimants using a tougher work capability assessment help people into work? J Epidemiol Community Health. 2015 Dec 8;70(5):452.

10.               Edmiston D. Welfare, Inequality and Social Citizenship: Deprivation and Affluence in Austerity Britain. 1st ed. Bristol: Policy Press; 2018.

11.               Whitehead M. A typology of actions to tackle social inequalities in health. J Epidemiol Community Health. 2007 Jun 1;61(6):473.

12.               Clayton S, Barr B, Nylen L, Burström B, Thielen K, Diderichsen F, et al. Effectiveness of return-to-work interventions for disabled people: a systematic review of government initiatives focused on changing the behaviour of employers. Eur J Public Health. 2012 Jun;22(3):434–9.

November 2021


[1] The participant seems to be referring to the ‘Two Ticks’ Scheme, where certified employers interviewed all disabled applicants who met the minimum qualifications for the position and considered them on their abilities. This scheme has now been replaced with the ‘Disability Confident’ scheme.