Written evidence from the Money and Mental Health (HAB0062)

 

Introduction

The Money and Mental Health Policy Institute is a research charity established in 2016 by Martin Lewis to break the link between financial difficulty and mental health problems. The Institute’s research and policy work is informed by our Research Community, a group of thousands of people with lived experience of mental health problems or caring for someone who does. This written submission has been informed by this powerful, lived experience testimony, as well as our wider body of research.

 

As part of this response, we draw upon a survey carried out between 20 August - 10 September 2021 of 309 Research Community members about their experience of applying for and receiving health and disability benefits. All quotes are from members of the Community who have participated in our research.

 

Our response addresses seven questions from the call for evidence. In addition to this response, we recommend reviewing our 2019 report The benefits assault course, which considers how the UK benefits system could be made more accessible for people with mental health problems.[1]

 

Background

        Nearly half (47%) of working-age adults receiving an out-of-work benefit have a common mental disorder, such as depression or anxiety.[2]

        Half (50%) of people in receipt of Employment and Support Allowance (ESA) claim for a mental or behavioural problem. One in three people claiming ESA for a physical or sensory health problem are also experiencing a common mental disorder.[3]

        Common cognitive, psychological and behavioural changes associated with mental health problems can make it harder to navigate the benefits system and engage with health assessments, as explored in Table 1 below.

        Our research finds that people with mental health problems’ experiences of health assessments for benefits are overwhelmingly negative. Only one in three (32%) were satisfied overall with their most recent PIP or DLA assessment,[4] and only three in ten (29%) were satisfied overall with their Work Capability Assessment (WCA).[5] These findings contrast starkly with the Department’s own findings of claimants’ satisfaction levels with the PIP and Work Capability assessment processes. 

        There are concerns at all stages of health assessments for benefits, from making a claim and participating in assessments to the outcomes of those assessments.

 

Table 1: How the cognitive, psychological and behavioural changes associated with mental health problems can make engaging in health assessment for benefits harder[6]

What is the problem?

What is the impact?

Difficulties understanding and processing information

People may take longer to process information or require additional prompts to provide the relevant facts. This can make answering questions accurately much harder, particularly where detailed information is needed to assess entitlements.

Memory problems

Difficulties recalling information can make answering questions on forms or in assessment interviews tricky.

Reduced planning and problem-solving skills

Faced with a complex problem, people can struggle to determine what actions they should take to resolve it. This can make getting through lengthy and complex processes difficult.

Reduced attention span

Concentrating on a task for a prolonged period, such as filling in a long-form, can be difficult.

Social anxiety and communication difficulties

Many people experiencing mental health problems struggle with some forms of communication. For example, our previous research focusing on essential services found that half of people with a mental health problem struggle to use the telephone, and one in six struggle to open post.[7]  It is likely this group experiences similar difficulties communicating with benefits agencies about health assessments.

Source: Money and Mental Health Policy Institute

 

Suitability of assessments

 

1. How could DWP improve the quality of assessments for health-related benefits?

Research Community members frequently tell us that their health assessments for PIP and ESA are often inaccurate, with seven out of ten (70%) members who were surveyed disagreeing that their WCA accurately captured the challenges they faced because of their mental health problems.[8] Three-quarters (75%) disagreed that their PIP assessment accurately captured the challenges they faced.[9] Improving the quality and accuracy of assessments is therefore crucial. We suggest two routes through which this could be done:

 

Match condition-specific specialist assessors to people’s primary presenting condition. Claimants often tell us that assessors often do not have enough knowledge about certain conditions to accurately assess them. Ensuring WC and PIP claimants are assessed by specialists with experience and knowledge of mental health will go some way to address these concerns.

 

Offer claimants advanced sight of interview questions. Another change the DWP could make to improve the accuracy and quality of their assessments is to offer claimants advanced sight of WC and PIP assessment questions. This would help claimants who have difficulties understanding and processing information, and those who struggle to think on the spot, to give fuller, more accurate answers to questions. Three-quarters (77%) of survey respondents[10] agreed that they would have been able to provide more accurate answers during their WCA if they had been allowed to read the assessment questions in advance, with 71% of PIP recipients agreeing.[11]

 

This information is already accessible via a FOI request. Giving people the best opportunity to prepare for their assessment and to be able to answer questions accurately would be a universal design adjustment that would mean people with mental health problems are not disadvantaged in the assessment interview.

 

This would ultimately support assessors to conduct more effective assessments and make more accurate recommendations to decision-makers - in turn potentially reducing the number of mandatory reconsiderations and appeals.

 

 

3. Do the descriptors for PIP accurately assess functional impairment? If not, how should they be changed?

Questions on PIP forms tend to focus on people’s physical ability to carry out activities, such as moving around, preparing a meal or picking things up, rather than functional impairments arising from their mental health problems specifically. Participants said questions aimed at understanding mental health problems did not cover the full range of their symptoms, so they often had to in effect translate how their mental ill health affected their ability to complete tasks.

 

We asked Research Community members about their views on how PIP assessments could be improved to better reflect how their mental health problems impact their day-to-day living. People overwhelmingly told us that the DWP should introduce more mental health-centric activities and descriptors to capture the day-to-day challenges that people with mental health problems experience.

 

The activities and descriptors are currently confusing and physical-health centric. They require a level of mental dexterity to interpret the question and provide an answer. This can be particularly difficult for people with mental health problems who may have cognitive processing challenges.

 

“All of the questions about how your health is affected by your illness were geared towards having a physical disability. I found it extremely difficult to explain that although I can physically do certain tasks, it is the motivation, ability to remember, communication, feelings of anxiety etc that affects me." Expert by experience

 

We have made a series of recommendations below about how WCA activities and descriptors can be revised to better reflect the experiences and circumstances of people with mental health problems. The principles outlined in the response to question 4 below also apply to PIP descriptors. and should be drawn upon when revising PIP activities.

 

4. Do the descriptors for ESA accurately assess claimants’ ability to work? If not, how should they be changed?

People are assessed against a criteria that is incredibly physical health-centric, which makes it difficult to accurately assess a claimants ability to work, when their primary impairment arises from mental health problems.

 

There are ten physical health activity descriptors yet just seven activities to assess a person’s mental, cognitive and intellectual functions. The physical health-centric nature of the descriptors and questions requires claimants to exercise a degree of mental dexterity.

 

“The paperwork took over 26 hours to actually fill in, that's without the hours of ruminating . It needs to be clearer as to what it's actually asking,  and in a better manner. The paperwork is directed at physical illness,  frustrating the process of describing the facets of mental illness. It appears to put physical illness as more important than mental illness. There needs to be more mental health descriptors.” Expert by experience

 

These challenges contribute to the fact that fewer than one in four people with mental health problems who responded to our survey felt they were able to explain how their mental health affected them during their WCA,[12] and only 17% said that their WCA accurately captured the challenges they faced because of their mental health problems.[13]

 

The DWP should improve WCA activities and descriptors to more accurately assess the challenges people face because of their mental health problems in the following ways: 

 

        All seven mental, cognitive and intellectual functional activities should be revised to capture fluctuating conditions, by adding timeframes to descriptors to reflect how often conditions impact a person’s ability to undertake specific tasks e.g. always, sometimes, never.  Many mental health problems fluctuate, either through crisis or periodic acute episodes of ill health where people's psychological or emotional state may reduce their capacity to cope with everyday tasks. Despite this, there is minimal provision for fluctuating conditions within the activity descriptors for WCAs.

 

        Introduce an activity descriptor for memory and the ability to retain information. There are no activity descriptors for memory. Activity 11 - “learning tasks” - begins to address the complexity of the task a person is able to learn, but does not capture their ability to retain information on how to complete that task, nor how this ability may fluctuate.

 

        Introduce an additional activity that assesses a person's energy and motivation to complete specific tasks. This should cover their energy and motivation to undertake basic tasks required for functioning e.g. eating, getting washed and dressed.

 

        Amending the descriptor on hazards to include not just reduced awareness of, but reduced regard for personal consequences to capture suicidality and risk to own life. Activity 12 addresses awareness of hazards but does not capture personal attitudes to hazards - specifically where people have scant regard for their own life - as is the case with people presenting with histories of suicidality.

 

7. Appeals data shows that, for some health-related benefits, up to 76% of tribunals find in favour of the claimant. Why is that?

Assessment all too often produces incorrect and inaccurate decisions, yet these flawed decisions are a result of poor processes which mean assessors are insufficiently equipped to assess people’s conditions, and claimants are not sufficiently supported to present the most appropriate medical evidence or answer assessment questions accurately.

 

Providing the right support to make the benefits system accessible to people with mental health problems is a fundamental starting point to ensure more accurate decisions are made first time round.

 

Routinely record claimants’ communication preferences and needs, and communicate via their preferred channel as standard. This would ensure people can engage via the channel most suited to their needs and where they have the best opportunity to put their case across.

 

Offer claimants a choice of venues for WC and PIP assessments that meets their needs and, importantly, which they are comfortable discussing their circumstances in

 

Consult with claimants on suitable dates and times of assessments with greater flexibility for responding to fluctuation in mental health, which may mean claimants are unable to participate on the day

 

8. Is there a case for combining the assessment processes for different benefits? If not, how else could the Department streamline the application processes for people claiming more than one benefit (eg. PIP and ESA)?

We would not support combining the assessment processes for PIP and ESA at this point, given the high rate of incorrect decision-making by the DWP. Introducing a single assessment against this backdrop would risk vulnerable people being left without any health or disability benefits. However, the department could streamline health and disability benefit assessments for the 1.6m people claiming both PIP and ESA by introducing small accessibility tweeks which would make a huge difference to people’s ability to navigate the assessment processes. 

 

Design online PIP and WCA forms so people can save their progress so claimants who struggle to concentrate or with clarity of thought, can step away and return to applications at a later date.

 

Pre-fille basic details for PIP award reviews and WC reassessment forms, such as personally identifying information to reduce the administrative burden on claimants having to repeat the same information multiple times.

 

Share appropriate data and supporting medical evidence between benefit applications. Almost nine out of ten (88%) Research Community members would be willing to consent to their medical evidence being shared between their WCA and PIP assessments to make the process of gathering evidence easier.[14]

 

However, any efforts to streamline this process would need to be done with care and rigorous external scrutiny to ensure that this process continues to benefit claimants, and that the government does not inadvertently use it as a precursor to introduce a single assessment framework.

 

10. What lessons should the Department learn from the way that it handled claims for health-related benefit claims during the pandemic: for example, relying to a greater extent on paper-based assessments, or using remote/telephone assessments?

Our research has produced substantial evidence that people with mental health problems welcome a range of communication channels to liaise with essential service providers - from financial services to the benefits system. The introduction of telephone and video assessments during the pandemic was a positive move for many people with mental health problems. It enabled them to participate in their health assessment from the comfort of their own home, without having to travel to an assessment centre which can be a challenge in itself.

 

“More phone or online consultations. The journeys, waits and face to face  are so incredibly stressful.” Expert by experience 

 

People should not be required to participate via one specific channel and should be offered a choice from which they can choose the channel most suited to their needs. In considering communication channels for assessments in the future, the DWP should ensure that people are offered the full range of assessment channels, from face to face, telephone and video.

 

Invariably, some communication channels will prove more cost-effective to run. Yet, to ensure that people are supported to communicate in the way most suited to their needs, people should be offered the full range of channels. More expensive channels should not be reserved for people who can make their case for them, as is currently the case with home visits. This change would also support the DWP to run more effectively.

 

Waits for assessments

 

14 a. How effectively does the “assessment rate” for ESA cover disabled peoples’ living costs while they wait for an assessment? Is there a case for introducing an assessment rate for other health-related benefits?

Health, disability and unemployment benefit rates are fundamentally insufficient to meet people’s day to day needs. Our research found that of people who were unable to work due to ill health, almost half (47%) disagreed that their income was usually enough to meet their everyday outgoings.[15]

 

“In the 3 months I had to wait for an ESA assessment things were very tough financially, the basic rate they give you is not enough to live on, I was extremely stressed about money.  Even though, after my assessment, I was given an increased rate, this is not backdated, so if I had gotten into debt I would have had no way to pay that money back.” Expert by experience

 

The ESA assessment rate of just £74.70[16] a week is wholly insufficient to cover disabled people’s living costs. Particularly, as this low ‘assessment rate’ is paid for 13 weeks - surviving on these low rates of income for an extended period can be incredibly hard. If a person is assessed as being eligible for ESA and sufficiently unwell to work, the rate paid is substantially more generous, at £110.75 a week, partly in response to the additional costs associated with long-term illness.These low rates of payment do not recognise that people applying for ESA are doing so because of a health condition.

 

The government should bring the assessment rate for ESA into line with SSP. Rather than moving claimants to a punitive assessment rate when they apply for ESA, the government should increase the assessment rate to be equivalent to SSP, currently £96.35.

 

While SSP is also insufficient for many people to meet expenses, our research demonstrates that when a person exhausts their SSP entitlement and are still too unwell to return to work they face a further fall in their income, of over £20 a week by moving to the ESA assessment rate. As a minimum, the government should bring the assessment rate for ESA into line with SSP to avoid unnecessary detriment caused by financial hardship while people are unwell, and smooth the financial transition from SSP to ESA.[17]

 

 

November 2021


[1] Bond N, Braverman R and Evans K. The benefits assault course.  Money and Mental Health Policy Institute. 2019

[2] McManus S et al (eds.) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. NHS Digital. 2016.

[3] Money and Mental Health analysis of Department for Work and Pensions, Employment and Support Allowance statistics, November 2020, and Adult Psychiatric Morbidity Survey 2014.

[4] Money and Mental Health survey. Base for this question: 298 people with experience of mental health problems and participating in a PIP or DLA assessment within the last three years

[5] Money and Mental Health survey. Base for this question: 248 people with experience of mental health problems and participating in a WCA for receipt of ESA within the last three years

[6] Bond N, Braverman R and Evans K. The Benefits assault course. Money and Mental Health Policy Institute. 2019

[7] Online survey of 2,078 people, carried out by Populus for Money and Mental Health. 11-13 May 2018. Data is weighted to be nationally representative.

[8] Money and Mental Health survey. Base for this question: 234 people with experience of claiming ESA/UC in the last three years.

[9] Money and Mental Health survey. Base for this question: 295 people with experience of claiming PIP in the last three years.

[10] Money and Mental Health survey. Base for this question: 227 people with experience of claiming ESA/UC in the last three years.

[11] Money and Mental Health survey. Base for this question: 281 people with experience of claiming PIP in the last three years.

[12] Money and Mental Health survey. Base for this question: 266 people with experience of participating in a WCA in the last three years.

[13] Money and Mental Health survey. Base for this question: 234 people with experience of claiming ESA/UC in the last three years.

[14] Money and Mental Health survey. Base for this question: 172 people with experience of claiming both ESA/UC and PIP in the last three years.

[15] Money and Mental Health survey between 17-29 April 2020 of 223 who were unable to work due to ill health.

[16] For people over 25

[17] Bond N and Braverman R. Too ill to work, too broke not to. Money and Mental Health Policy Institute. 2018