Welcome to the second inquiry session for the pathways to work inquiry. It is a pleasure to welcome our first panel for this session. A warm welcome to James Taylor, Jonathan Andrew and Mikey Erhardt. Would you like to introduce yourselves and the organisations that you represent?

Good morning. I am James Taylor. I am executive director of strategy at the disability charity Scope.

Good morning, everyone. I am Jon Andrew. I am the head of public affairs at the mental illness charity Rethink Mental Illness and our sister charity Mental Health UK.

Good morning, everyone. I am Mikey Erhardt. I am a campaigner at the disabled people’s organisation Disability Rights UK.

My first question is in relation to sick and disabled people’s current experience of the incapacity and disability benefits system. What would you say that is, both positive and negative?

Overall, the current benefit system is not fit for purpose. We have seen that time and time again and know from many disabled people that there is a real lack of trust, a real lack of engagement from the Department for Work and Pensions and jobcentre in terms of supporting individuals. Many disabled people who speak to us at Scope tell us that the system is focused on monitoring compliance rather than supporting them. It is focused on trying to understand what people cannot do rather than what they can do. We hear from many people that the jobcentre is impersonal and ineffective. On top of this, the level of benefit is nowhere near enough for the people who need to make use of welfare payments to be able to survive. The overwhelming experience of most people is one of negativity rather than one of positivity. Of course, there are good cases where people receive a good outcome, but overwhelmingly many people we speak to feel like they are written off and feel like they are being punished simply because of their disability.

I agree with a lot of what James has said. I will add from the mental illness perspective. First, we accept that an assessment to establish your extent of illness and capability for work is unlikely to ever be a particularly comfortable or pleasant experience. Even in a utopian world where the Government do everything right, it would still have challenges. We recognise that. However, a lot more could be done to make it a lot better than it is and make it a lot more trauma informed, particularly with mental illness. The DWP is always keen to state that you will be assessed by a health professional, and that is true, but there is no guarantee that the health professional has the relevant expertise that matches your situation. An example of that would be somebody getting an assessment because of complications to do with their schizophrenia and psychosis and being assessed by a physiotherapist. That is some low-hanging fruit. That is not quite good enough. This can lead to situations of worryingly bad practice. We hear about somebody explaining to the assessor they have had suicidal ideation and then being asked, “If you have had suicidal ideation for so long, why are you still here?” We hear of people self-harming in the session and smacking their head against the desk and being told not to make a scene, and people having to explain that their eating disorder does not mean they cannot physically eat. They should not get questions about whether they can raise their arm to their mouth. It is not an easy job being one of these assessors. They need more help, but these are not just a couple of bad cases; we hear this a lot. A lot can be done there to make it more trauma informed from a mental illness point of view.

Nothing that has already been said is stuff that we disagree with. From our perspective, the process itself makes people sicker. We did research with Durham University looking at specific elements of how the assessment process particularly for PIP works. Of the respondents we had, around 84% said, “The assessment process has damaged my mental health.” That is removing all the other aspects of your life as a disabled person that might make your mental and physical health worse. The pure assessment process when applying for benefits—not getting the right level or kind of support, but just physically applying—made their mental health worse. The instances that Jonathan has given are not surprising. That is the experience that lots of people have. The pressure for lots of disabled people is it feels like you are justifying, in some ways, being in the room—even applying in the first place. Your relationship with an assessor is not working out what your need is. It is justifying that you are applying for benefits in the first place and that you deserve to even be there. All this will probably get worse when the pressure now is to reach an arbitrary fiscal figure on how many people do not get support anymore. That will get worse. From our perspective, you cannot undervalue how dangerous that is. The tangible effect of the changes that are being proposed is pretty obvious and you would be naive to think that you can already cut from the system a level that would be in some ways palatable or manageable. There is not. These cuts will lead to deaths, most likely. According to the National Audit Office, in 2020 there were at least 69 deaths by suicide as a result of problems with benefit claims. That report spoke about how it is probably quite a lot higher because the DWP failed to measure and lots of other reasons why that already existing level of deaths purely caused by the benefit system is higher. It is quite likely that, with the way we are going, the trajectory is that that will get worse. The assessments will get harder. The stress will be higher. There is no way of sugar coating that.

I notice that Ellen Clifford has joined us. A warm welcome, Ellen. It is lovely to see you today. My first question to the panel, if you feel up to it and if you are able to respond, was about how the current system is for sick and disabled people, both positive and negative.

Thanks, Debbie. I agree with everything Mikey has said. The assessment system does negatively impact on the mental health of people going through it. It moves people further from employability, because every time you have a reassessment there is the fear of financial insecurity and then the trauma that is involved with repeatedly going through your history and focusing on the things that you cannot do and feeling that you are having to justify yourself to someone who may not trust you and may have negative views of you. When you get the assessment report back and it does not accurately portray what you have said to them, it causes a distrust in the system. I have had people describe it to me as feeling violated because they have said such personal information and have been through this difficult experience. To then have that not properly represented can be very harmful for people. The other big issue that people talk to me about—and one young woman with learning difficulties, Emma Roland, gave testimony to the United Nations on this—is the experience of people who have limited capability for work but who do not have a realistic prospect of paid employment and have this continual experience of applying for jobs and being rejected and of doing work placements continuously, never leading to a job. We know that there are huge amounts of discrimination against people with learning difficulties within the workplace. Productivity questions also get asked by employers. I know an issue comes up repeatedly about whether people with learning difficulties should be exempted from the minimum wage. She is a young woman, as are many people I speak to, who desperately wants a job and who wants to have that status you have in society. Particularly since the WRAG cut in April 2017, it is a low amount of money for people to be expected to live on, but there is this additional component of the continued rejections then creating trauma and creating mental health difficulties for people. Overall, one big problem with the system is that it is not trauma informed and it reinforces people’s trauma and creates new mental distress for people. What works is that when people are found eligible, it keeps disabled people in relative poverty as opposed to destitution. If that is the best we can have in our lives, then we would much rather have that than the destitution. The big fear, of course, with the Green Paper proposals is that that safety net will be taken away from huge numbers of people on such a scale that it is quite difficult to fathom how it could be considered good for society. I will leave it there.

Thank you. On that, I will carry on with you, Ellen, and we will go down the panel in the reverse order. Thinking about the point that you have made about it only covering people from relative poverty, what do you think about those who say that the current system disincentivises people into work?

I find that quite curious. I am not aware of any evidence base for those claims. I am quite bemused sometimes by conversations about trying to get people into work that do not seem to take into account the real barriers that people face. If we are talking about people who have limited capacity for work and work-related activity, quite often we are not talking about a skills deficit or a lack of education. It is the fact that many people in that group have many days and many hours every day when we are simply unable to function due to extreme levels of pain, whether that is emotional or physical, or due to the significance of physical impairment. For example, for people with neurodegenerative conditions with high levels of support need, it can take a few hours every day to get up and dressed. Then continual medical appointments and therapeutic appointments are required. Having to travel to those does not leave a realistic amount of time in the day and certainly not the energy within the day then to be able to take on paid work. Many people I know in the LCWRA, however, still contribute to society in important ways, but it has to be extremely flexible. It has to be around those periods of time when they are able to function. It is difficult to find paid work where you have that extreme flexibility. I know that some research has been done by Ben Geiger and Catherine Hale looking at that and how flex-plus jobs have only benefited people with childcare so far. Those jobs are quite rare. For example, I know a woman with a neurodegenerative condition. She is unable to breathe on her own anymore and unable to clear her lungs. Her life is spent in and around various medical appointments. She is a trained counsellor and she counsels two people for free but on the basis that there is that extreme flexibility of appointments being cancelled at any minute. She does training. She is involved with her local council as a governor, I believe, for a local school as well. Many people contribute in ways that do not fit within the paid workplace environment. Like I said, there is not an evidence base for this and it is certainly nothing that I have ever witnessed.

Thank you. Mikey, do you want to add to that?

I want to echo everything that Ellen has said. From our perspective, we would not want anyone ever to think that their worth is dictated by whether or not they have full-time paid employment. It feels like the cut-through from the Green Paper proposals is that you are eligible and deserving of support if you are working. If not, you are in some ways a different class of citizen. It is incredibly distressing and it is an experience that loads of disabled people I speak to all the time already experience. We are opening that up for more and more people. The problem with getting people into work is the world of work. It is nothing to do, in some ways, with the benefits system. The workplaces are hostile to disabled people and our needs. They are pressurised, competitive and in a lot of cases in some ways dangerous and destabilising environments. When you think about the precarious work that is growing more and more in this country—low-paid, zero-hours contracts—it is quite often physically and mentally intensive. Those are the jobs that in lots of places are the only work available. Pushing people into the risk of those jobs will not achieve much. All it does is put people in dangerous and worrying positions. Their health will get worse even if they do pick up work. An example that is useful to think about is that there is no quick fix for this. The way to think about it is not just putting a bit more onus on employers, doing something like the Mayfield review and then saying, “Employers need to be a little bit better.” It will be difficult to drastically improve the world of work for disabled people quickly and at the pace you would need to even mitigate in little forms the Green Paper cuts. I was looking at some Unison research around reasonable adjustments, which is one of the few tools disabled people have to make their workplace better for themselves. It said that around 74% of disabled workers reported being refused some or all their adjustments. When we go back to thinking about the workplaces and the precarious work, those are also often the least union recognised workplaces, the ones with essentially the least flexibility for people. Yes, overall, when we are thinking about the world of work, it is beyond this Committee. It is not the benefit system. It is work.

I will keep it quick; I know you have a lot to get through. I can see why, when we talk about economic inactivity in general, it is often couched in terms of incentives. When it comes to incapacity benefits, at the point of entering the system it is not about incentives. It is about capacity because the whole premise of incapacity benefit is that you do not have a straightforward choice between working and not working. This does become a bit more relevant at times further in the system. People who have been on LCWRA for a long time might feel they are slightly improving and might feel like they want to try certain types of work. We hear a lot that people are scared to put their head over the parapet in any way or engage in any way because that might lead to them being assessed. The right-to-try principle in the Green Paper we think is right. We would do whatever we can to help communicate it. There is a real lack of trust, though, and it will be quite hard to communicate to people and ensure people know they have that right, but that is a move in the right direction.

To echo what other panellists have said, this is beyond the welfare system. It is more of a workplace issue and an employer issue. If the jobs do not exist or, as Mikey has been saying here, it is unsuitable and unstable work, you might succeed in moving some people off benefits and into those jobs but quickly probably back on to benefits again. It will do little to solve the problems the Government intend to set out. For a lot of people, work is not an option or an outcome, as Ellen has talked about, and we need to ensure that the Government understand that and those individuals feel supported. People who go through stressful assessments and receive some financial security from the welfare do not want to jeopardise that at all because they are worried about sanctions or conditionality or whatever else exists in the system and, therefore, hunker down and try to exist off the benefits they are being provided with.

Thank you for joining us this morning. How effective is the personal independence payment at helping people with the additional costs associated with their disability or their health condition?

Overall, it has limited effectiveness. Our research at Scope, “Disability Price Tag”, looks at the extra cost of disability. We calculate that a disabled household in the UK would need £1,010 on average to have the same standard of living as a non-disabled household. That is far higher than the highest rate of PIP that is available to those households. From looking at those two things, we say PIP does not go far enough in dealing with the extra costs that many disabled people face. It is a broad spectrum. Some disabled people have few extra costs and PIP might work for those. However, when you look at it at a national level and for the whole population, it is clear that the extra costs of disability are far higher than the financial support that is available for individuals to meet those costs. Those costs have been going up with inflation. We have seen energy price rises and other bills going up. PIP has not kept up with those.

Yes, I echo a lot of that. It is not usually sufficient for people, but it is still important. We have done some work since the Green Paper came out looking at what people with mental illness are spending PIP on to ascertain what will happen when they lose it. We have found so far that one in two is using PIP to access private medical treatment because they are on waiting lists and cannot get help with the NHS. You are currently eight times more likely to have to wait a year and a half for treatment if your condition is mental rather than if it is physical. In a way, that suggests that PIP is filling gaps elsewhere in the system and we find that concerning. There has been a Government drive on getting down waiting times, but specifically for elective waits, as they call them, which is physical. We cannot quite see why more is not being done to tackle what we see as the root of the problem rather than trying to trim off things from PIP.

Yes, it is the same experience for us. It is important for the Committee to remember as well that PIP is a passport for other forms of support. Carer’s allowance has been mentioned quite a lot. Roughly 150,000 carers will lose that allowance if they also lose PIP through the tightening of the assessment criteria. PIP is an important gateway for a lot of people to in some ways validate their experiences and access further support. It is a worrying trajectory to be thinking about how we can make that harder for people. An assessment that is similar to the WCA, which I assume we will get on to in a bit, is dehumanising, frustrating and scary, fundamentally. Then to think we will make that harder, there is not a lot more to say on it.

I echo everything that has been said. Increasingly, people are having to use PIP for essentials because of the increase in cost of living. They are not able to then be able to use the PIP for those extra disability costs. However, where we can, where there is that possibility, it is making up for not just the waiting times in the NHS but, as has been mentioned, also private therapy. For people with mental health, the mental health system is less able to provide services that tackle complex trauma. A lot of the interventions are short term and therefore limited in their effectiveness. It is very much a case of see the psychiatrist, get stabilised on medication and get discharged. Lots of people in the mental health system live with enduring and severe mental distress and do not regularly see any form of mental health professional unless they use their PIP for private therapy. In the social care situation, many people need but do not receive any form of ongoing social care support. PIP allows you to pay for people to assist you with domestic tasks and personal care or pay for travel for family and friends to come and provide support to you because that is lacking. It does not go far enough.

To follow up on that, what would be your response to the argument that we have read reported in the press that somehow too many people are claiming PIP on mental health grounds?

That is probably one I should go first on. Rising mental health need is a complicated issue. I can see intuitively why some people look at the rising need of mental health and come to the conclusion that this must be being driven by semantics and we must be changing the goalposts for what counts as mental health, especially when we hear about it a lot more than we used to hear about it. I get that. However, if you interrogate the evidence, it is clear that that does not tell anywhere near the full story. There is talk about self-diagnosis a lot but the statistics that are relevant to DWP or health are all medical, so we can park that for a second. Medical diagnoses of various mental illnesses are going up. You could do the Nigel Farage argument and say that that is because doctors are getting it wrong, which is quite a big claim to make about medical professionals, but it is possible. If you then interrogate it further, the number of people appearing in hospitals with severe self-harm has also gone up, especially among young girls, and the suicide rate is now at its highest point than it has been at any time in the 21st century. They are not miscounting the bodies. Sorry to put a fine point on it. We have to get real about the fact that, yes, there is rising awareness, but there also is a rising crisis. That is not me saying that rising awareness has no impact on finding more cases, but it is a bit like if you look back to 2020 with covid; introducing mass testing, of course, found more covid cases. That did not mean that we were misdiagnosing anyone. It meant that we were locating more of the cases, and that was a good thing. To use the covid metaphor, we are seeing now a mixture of looking at mental illness more and finding more of the real cases, which were always there but we are now identifying, while there is also a new variant or a spike of something happening. A couple of trends are happening at the same time. That is not easy for society. It is a challenge, but it is right that we have looked under the rock labelled “mental health” and tried to address this, and it will mean some alarm when we see how bad the problem is. That does not mean the problem is not there. We cannot wish it away.

I want to come back to the issue you were talking about on the funding and what PIP was used on. You said that one in two people with a mental health diagnosis quite often use it for private medical expenses. I am guesting this morning from the Health and Social Care Select Committee so I am interested in your take on where you think mental health services could and should improve to start addressing this problem. We have talked about the other end where we are getting people back into work, rightly so—that is fantastic. All those things need to happen. In terms of the mental health system, I wondered if you could talk about the funding you think might be there to help within the 10-year strategy that is coming forward.

Yes. The mental health strategy, from a policy point of view first off, cannot just be done through the Department of Health. We need a cross-governmental approach. Luciana Berger, now Baroness Berger, did a lot of work on this before the new Government came in, and we submitted evidence and did a whole look into how a cross-government plan could work, which we have not seen published yet. We would like to see the results of that. Ultimately, you need to look at prevention and try to wire in interventions early in schools through employment. With physical health, yes, the NHS is there, but you also have PE lessons in schools and nutrition on menus and things that are designed across the system with your health in mind. That infrastructure is not in place for mental health. That is one thing. We want a cross-departmental plan. I mentioned the waiting lists. That side of things is still bad. The mental health investment standard—and I will not go too far down this tangent—ringfenced some money so some of the money is already there. It needs the system to direct that towards targets in mental health waiting lists. That would be an important move that the Government could do, without committing much additional resource.

It is not just the mental health system. There is also the social care system. The mental health system is focused on recovery, which is one thing, but people have or may always have those ongoing support needs. Unless you are able to access that through the social care system, you will not get that unless you have PIP to pay for it yourself. The mental health system does not provide that form of support.

Will the Green Paper specifically increase or hinder the chances of finding employment?

You cannot cut people’s support and then think that will lead to people going into work. It is fundamentally not how it works. We will have more people feeling at risk and not getting the support they need. PIP is not contingent on work; it is meant to address the additional costs that you have as a disabled person that result not from some act of God but from the way we have built society. Those additional costs almost always accumulate across how decision makers in the Houses of Parliament have over years excluded us. None of that will change as a result of cutting our support, as proposed in the Green Paper. It will make it potentially harder for people to find work and to have the solid base that they might need to feel like they can push on. I wanted to pick up the right to try because, in essence, yes, it is a small positive change, but the way it is being proposed to be implemented is still not anywhere near what you would need. The right to try as written out in the Green Paper says you will not be reassessed immediately when you report that you are trying work. You would need to have there the guarantee that, if you find work and it does not work out, you can return to the social security system where you were without risk. You are still putting risk in for work there. You are still saying to people, “If it does not work out, you will be reassessed and you may lose out.” That element of risk still prevents a lot of people—especially, as we have already touched on, with the world of work being hard for disabled people. You will still have that barrier there where people will be worried that it will not work out and what that means.

Specifically, how do you see the additional £1 billion investment in employment support sitting with the cuts to income support for disabled people? They seem contradictory. What are your views on that?

It is frustrating because there are snakes and ladders. There are things that help and things that then bring you back to where you were before and that is difficult. As you say, there are some contradictions. Some good thinking was done behind the scenes in the DWP about some of the issues underlying economic inactivity. Investing in employment support is the right thing. The right to try is the right thing, even though, of course, as Mikey rightly points out, they need to work out eliminating risk from that. Then the Treasury comes along and says, “We need £5 billion of cuts,” and that ends up undoing all the good work. If you imagine a spectrum where on the far left is someone who is a long way from work and on the far right is someone who is close to work, some measures will chip away at it and move people slightly in the right direction, but anything that will increase poverty by hundreds of thousands, as their own Government assessment says it will, is like a gale-force wind in the other direction. It is quite frustrating because it isn’t that there wasn’t good thinking; it is that it clashed with short-term incentives about trying to cut money, which has undone a lot of that good thinking. That is how we see it.

I 100% agree with that. First, it is impossible to know whether the measures in the Green Paper will lead to any people moving into work because it has not been scored or assessed by the OBR. The DWP could probably publish its own assessment of its own measures on getting people into work. That would be quite helpful for MPs who are expected to vote on some of these measures in a couple of weeks’ time. Jonathan is right. The huge potential investment in employment support for disabled people is completely undone by making millions of people financially worse off, with many hundreds of thousands into poverty, and many not being able to receive benefits at all—benefits that might support them in finding a job in the first place. The increased investment in employment support could be positive. We are yet to see how many disabled people that would support in finding work. It is, sadly, completely offset by the sledgehammer that is £5 billion to £7 billion worth of cuts coming.

On the employment point, given the link between Universal Credit, health entitlement and the daily living component of PIP, how might this in your view affect people with fluctuating conditions and mental health concerns accessing benefits and engaging with employment?

It will be made much trickier. It is already a complicated system now. A set of measures is being put on top of the complicated system, which will make it even worse for many people. The Green Paper also talks about some short-term unemployment insurance as well, which I am sure the Committee has looked at. That fails to acknowledge that many conditions are long term. It feels to us, and to many people that we have spoken to, like a real disconnect between people’s lived experience of trying to find work, and navigating a complex system that distrusts them, and the measures there that are supposed to support them in the first place.

I would add that a number of different elements within the system and the way it works in terms of engagement with Universal Credit act against us being able to move into work as well. It would have been a good starting point to be able to work on those with the DWP before having cuts and before employment support is put in place. There are many examples of things, but council tax is one example. If you have fluctuating earnings, every time you earn above a certain threshold you lose your council tax support, but you do not get it back automatically when your earnings then drop again. You are in a continuous cycle. If you want to try work and it is not salaried employment on a stable amount every month, you are then having to continuously reapply for council tax support. Another example is how the DWP system at the moment does not allow for fluctuating capacity. Someone comes and visits you and assesses your capacity and decides that someone else will, a third party, or you have to do it yourself and realise that there will be times when perhaps you do not have the mental space to be able to report your income and expenses accurately. It is disempowering to be labelled as not having capacity. That is something that could be sorted out. Of course, we have the situation with access to work. My fear is that the money that will be invested in employment support will be wasted because too many problems within the system are not addressed in the Green Paper and because of the other issues with long-term conditions. A work coach will not be able to fix the real problems for people not being able to work. The survey published said that 200,000 people would be able to work now with the right support and with the right job, but it was also interesting that that survey listed the barriers and the reasons why people are not able to work. Those things are not within the remit of a job coach to help you with. We have already talked about waiting lists for mental health and social care support. I worry how useful that money will be unless other things are fixed first.

I want to briefly, because time is against us, pick up on cost shunting, not just within the DWP but perhaps on to other public services, and perhaps on to health particularly. We touched on suicide. I am also alive to the issues around drugs and alcohol and whether this might be pushing people more towards leaning on that as a crutch, in this really challenging world that we are beginning to enter.

The one that we pick up on in particular—Ellen mentioned it already and is important to think about due to the scale of the crisis in that sector—is social care. PIP is used and benefits are used quite often by local authorities to figure out how much personalised support someone can afford. If you are assessed as not eligible for PIP anymore, you are suddenly losing lots of social care support. Your local authority is also, on a pragmatic side, trying to figure out if it can raise the revenue it needs for social care. That problem will not emerge overnight but over six months or over a year. It is not as if our local authorities are flush with cash right now. Social care will get worse. That leads to further issues for disabled people and loss of independence. We do not have a social care system that is operating particularly well in regard to what disabled people want out of it and what they deserve out of it at the moment. Those things will get significantly worse.

I have nothing more to add. Retweet.

If I could add, the Disability Policy Centre has calculated that every £1 lost in benefits will push £1.50 on to other services. I agree with everything Mikey said. There is also the issue that people having their PIP reduced will mean that the amount that local authorities can charge for social care will be reduced. There will be huge additional pressure on other services. There are also gaps where services do not exist. For example, there is no longer in my borough any form of outreach for drugs and alcohol at all. When people are consigned to a life in poverty, there is no hope for people. When people do not have hope, they turn to drugs and alcohol. I worry for our communities and the impact that these cuts will have.

The Government have said they will introduce an additional premium for those with the most severe lifelong conditions who will never have to face a reassessment. Does that alleviate any of the concerns that you have?

I have a short answer: no. Not to be glib, but we know so little about how this will be assessed and how this will work that there is no way we could be confident in it at face value. The only thing that we have understood from the last months of discussion is that this group will be small. It will be a small cohort of people. If that is all we know and all we are being told that we are working off, no, we cannot be confident in it because we are working at a number. In the same way that the Green Paper seems to establish a number saved and work backwards, we are doing the same with this premium.

We have no idea how much this element will be, how much it is worth, how people will receive it or qualify for it or who will be eligible. I agree with Mikey. The answer is no.

I have one thing to raise on mental illness. Some of the language in the Green Paper about this premium suggested it would be available only to people who will never be able to work and have the most lifelong conditions they will never recover from. Mental illness, even severe mental illness, can be quite fluctuating. Even in a severe case, it would not be desirable to say that somebody who has severe psychosis in their 20s will never be able to work again. That bar for mental illness is quite impossibly high. Anything that will help protect people, of course, is good, not bad, but we need to see a bit more detail on this and how it will work.

Do you have thoughts on eligibility? Where would you set that level? How would you assess the people who qualify for that?

It is incredibly hard. There are a lot of grey areas and I could not design something specific in the here and now. One important consideration would be not to make it condition specific to ensure that if you have X condition you qualify but not if you have Y condition, because you can have milder or more severe conditions. We would need to look at it in the round with everything else and it would need to be done through consultation with people who have used these systems and with people who are experts in mental illness to assess that properly.

That is right. You want assessors who are experts in those conditions as well rather than the generalists who exist in those roles at the moment.

Thank you. Ellen, did you want to add anything or are you all right?

No, not on that. Everyone has covered it.

The Government are planning to restrict access to the daily living component of PIP and then do a review of PIP. What benefits would doing the review before restricting access have?

You have probably answered your own question.

Yes, I know.

It feels counterproductive to commit to cut personal independence payments to meet an arbitrary financial target and then do a review of the benefit in the first place. We would far rather see the review happen first to understand what changes can be made and should be made, rather than this big, arbitrary cut that will be voted on in a couple of weeks’ time.

This speaks as well to the fact that the Government have not shown their working so it is hard for us to work out the logic behind some of the changes to the PIP criteria. The new system has a lot of emphasis on the importance of scoring four points in at least one category. That means that person A gets 14 points on a PIP assessment but does not get any benefit because they have seven twos, and person B gets eight points but does get a benefit because they have a four and two twos. I am trying to work this out and thinking, again, “They have not shown that working. I am not quite sure why that works.” For mental illness in particular, when you look at the difference between fours and twos, you hope you will see something that is fairly stark, but it is incredibly arbitrary. For mental illness, often you get two points if you require prompting to do something or four points if you require assistance. Imagine somebody who has a severe eating disorder and needs someone with them when they are cooking to make sure they are eating, not counting calories, not panicking and everything else. They need that. It will probably count as prompted because in most cases prompting is the mental illness version of assistance. It is like mental assistance. They have drawn these lines and made that distinction incredibly important between twos and fours, but they have not explained why. A consultation would have helped a lot of my own confusion and hopefully some of yours as well.

Yes, that is an apt summary of where we are at. In fact, it has taken an FOI by Benefits and Work to understand the scale of the cuts. Around 1.1 million people will lose access to daily living. That took an FOI. The DWP was not willing to share that. That speaks to a process of reaching an arbitrary fiscal figure and working backwards. From our perspective, the whole process has been pretty, for want of a better word, shambolic. We took ages to get the different formats that disabled people need to engage with the paper. To be honest, those additional formats are just for the Green Paper and the consultation itself. It has nothing to do with the additional evidence pack that realistically you need as an individual to be able to assess what the Green Paper is asking. Yes, the PIP review should have come first, and we would have loved to have been talking about that instead today and talking about how we can make that better, but no, we will now look at how we can make something that is probably significantly worse maybe better in the future.

Yes. When we talk about impacts, there is the number that has been reached as to how many people will end up with an actual loss of PIP. In terms of impact and in particular the additional pressures on other services such as mental health services, we have to look at the fact that lots of people will be at risk, many more than those who may end up with a loss. If you take the 1,325,000 figure of existing claimants who do not get four in any area and yet, according to the OBR’s—in their words—highly uncertain judgment, only 800,000 will end up losing it, hundreds of thousands of people will go through the appeals and mandatory reconsideration processes, which we have already explained create trauma not just for us but also our friends and families and everyone who goes through losing that income and then having to fight for it to come back. Also, people who may end up absolutely fine and people who currently get four points will still be scared because the awarding of points at assessment is done so arbitrarily. Nobody will feel safe at all and that means a much wider impact than just those people who will lose it. As people have said, a huge amount of information is missing. MPs should not be voting on this when they do not have that information.

To put a positive spin on the world that we are in at the moment, bearing in mind that the clock is ticking, what are some key principles or culture to apply to PIP to change it for the better that you want to see reflected in a reformed PIP system?

I could say four things quickly. First, we have heard a lot about mistrust. There has to be a principle around trust and belief in claimants. We need to see more accurate and less burdensome PIP assessments in the first place. We know lots go to tribunal. Lots are overturned. Lots are found in the claimant’s favour. The third thing, as I mentioned in the previous question, is having appropriate expert assessors in specific conditions. Finally, we talked a little while ago about the extra costs of disability and PIP not meeting those extra costs. We think there is something in an enhanced PIP rate that supports people to cover the essentials.

PIP could also improve by establishing itself not as distinct and separate from our health and social system or from our housing system. Our benefit system is societal infrastructure that has to fit into those other Departments, too. Part of the reason these cuts are so drastic and will have these knock-on effects is because we are treating them as if cutting £5 billion from the DWP does not affect anyone else or do anything else anywhere.

I would add to that stability. One in six PIP claimants is in work and we rely on the income from PIP to be able to remain in work. However, the constant fear of reassessments and the reassessment process moves us further from being able to stay in work. Fewer reassessments would be helpful to people’s health and wellbeing and pressures on mental health and the NHS.

I was speaking to somebody only the other day who was describing PIP as a safety net around the broken access to work system. Thank you.

Can I ask you specifically about the plans to restrict access to the UC health element? The Green Paper highlights the 150,000 young LCWRA claimants from 16 to 24. Can I ask for your views on this element of the proposal, and whether you think the actions aimed at supporting more young people through right to try—we touched on that earlier—the youth guarantee and additional investment in employment support will be effective in supporting disabled young people into work?

It is such a small number of people under 22. Delaying access to the health element of UC for people under 22 will have disastrous consequences. It risks increased poverty, loss of independence and barriers to employment. It is not clear whether all disabled claimants under 22 on UC will have to look for work or what employment support will be available to them. Like many of the measures put forward in the paper, a lot of the impact and detail is not there and is unclear. We are clutching at straws as to the intent of some of these things. We would be concerned if the minimum age for the health element was raised to 22.

Things like right to try are great, but they are relevant only if you are able to work. What happens if you are under 22 and you cannot work? Adolescence is by far and away the most likely time for you to experience mental illness. I have lost count of the number of people I have met through this job who went to university and then were hit hard by psychosis and schizophrenia. Your early 20s become almost unsalvageable at that point, a difficult time. Of course, it is concerning that more young people are out of work and more young people are ill, but we should address the causes of that. If there was a worrying rise in youth asthma, we would not restrict access to inhalers; we would look at how to help address the underlying problems. It sounds absurd when we put it in physical health terms, but a strange logic still seems to apply with things that people link to mental illness that if you take things away from people, they will realise they are not ill and go back to work. It does not work like that.

Yes. It feels tantamount to saying to people under 22 that their disability, impairment or long-term health condition is not as real as it will be when you are 22. It is completely arbitrary. You are right to say that young disabled people are a small cohort, but it is still a lot of people. If this goes through, you are saying to tens of thousands of young people, “Your experience is not real. It’s not valid. Don’t worry—it’s fine because your peers are going off to work or maybe to further education, but you can’t because of an arbitrary decision we have made.” It is really dangerous and it fails to acknowledge all the reasons that young disabled people end up in a scenario where they might not go on to further education or to work, not that those places are particularly great for young disabled people at the moment. It does not address the failing SEND system, for instance, with its outcomes. All it is saying to young disabled people is, “Good luck,” essentially.

To build on what others have said, if young people receive adequate therapy, intervention and support, it can set them up for better life outcome. If their experiences are negative, Mikey spoke about how it could make people feel when their support needs are not being met, and the material deprivation they may experience as a result. Negative experiences will lead to longer-term negative life outcomes, which then require intervention and support throughout people’s lives. Getting those early years right is important.

Thank you very much for those answers. Building on the point that Ellen has made there, if you were engaging with the Government on how we can support young disabled people, who want to work and are able to work, into work—and clearly there is opposition to these proposals from the panel today—what would that look like? What would you look to establish to support more young disabled people into work?

The most obvious thing is that removing benefits does not lead to more people getting a job. The previous Government consulted on changes to the work capability assessment. The OBR found that removing £5,000 from 400,000 people would lead to only 11,000 of them getting a job. This bizarre thinking, as Jonathan articulated well, that removing money from people suddenly helps them find work is nonsense. We want to see that financial support remain and investment in the SEND system, as Mikey talked about early on, investment in apprenticeships, and investment in specific schemes for disabled people, working with employers, working with disabled people, with leaders in industry who can come and speak to young disabled people, because there are few role models. This goes beyond the welfare system, but thinking that removing this benefit, or making it far harder to get, will lead to the outcome that you want to have is nonsense.

There are a couple of things. There is dealing with the underlying problems of why we have high illness, mental illness and other illnesses, which is why I talked earlier about the prevention agenda, waiting lists and so on. There is no quick fix there, but those things need to be looked at. In terms of helping people who are able to do some work—and we know most people who have mental illness and are out of work do want to be in work—the Government are doing some of the right things in terms of investing in employment support. Our charity runs IPS and IPS plus services. We run a service called Into Work, which works with employers and people who are out of work and tries to bridge some of those gaps. As I said before, it is a bit frustrating. I feel like the Government are doing some of the right stuff and the wrong stuff at the same time and it is cancelling out. That might be to do with different incentives in different parts of the Government. I cannot speculate, but people in the system know the right things to do. As I mentioned, Luciana Berger has done a lot of great work on this. Officials in DWP have done a lot of great work on this. If the answer to making this work is to take £6 billion out of people’s support, it will not work. It will not help.

Nothing to add from me.

I have a final question. Another group of impacted disabled people who might find it challenging to access work is older disabled people who have been out of work for a long period of time. We know the challenges for that cohort to get back into work. Perhaps an erosion of skills has occurred over many years. What are your views on the support that is required for that particular cohort?

We have heard a bit about reasonable adjustments and the few employers who are willing to be reasonable and make them. We know that many disabilities are acquired in life rather than people being born with them. As we get older, more people acquire disability. We are seeing employers not being willing to make those adjustments. We are seeing employers not being willing to have the flexibility to support people with fluctuating conditions. The DWP across government could be making some positive noises and introducing measures, particularly around flexible working, particularly around sick pay and particularly around recognition among employers of disability. This is one of the biggest barriers. Everything we have talked about is quite structural, but it all leads back to attitude and issues towards disability and disabled people. That is particularly acute when you are older.

Quite a lot of the attitudes and how we are perceived as disabled people bleeds out from the benefits system and the process that assesses you in that way. It says to most people, “You are not as disabled as you say you are,” or, “You are not deserving of state support in the way that you feel you might be.” That attitudinal stuff bleeds out from the DWP system. For a lot of people, it is difficult not to internalise that, especially if you are older and have been through quite a few processes and have been doing this for years. In terms of making the world of work better, access to work is not a perfect system or particularly expansive, but a lot of tangible improvements can be made that would make working easier for older disabled people. One thing to remember, especially around the older cohort, is that quite a lot of those people have been made unwell by work. For a lot of the people who come up in that cohort, it is musculoskeletal as a result of working. There has to be that consideration as well through things like the Employment Rights Bill of making work safer for people because you will perpetuate this out and do it again.

A quick question. Maybe Mikey is speaking across the spectrum of disability. So that I understand what you think of the review of the PIP assessment that is going on, do I understand you to be suggesting that the problem is the whole capability assessment itself and the idea that we should judge people on their functional abilities or disabilities? Are you suggesting it would be better to have a system that is simply based on diagnosis rather than potentially quite an intrusive assessment of people’s functional abilities and disabilities? How should we do it better? I guess that is what I am asking you.

To do it better, I would steer clear personally of saying that a diagnosis is the only way to formalise your experience of disability. In the first session, you heard from Ben—I cannot remember which university, so sorry to his university—who talked about how we push people to medicalise their experiences because that is the only way to access support. In theory, the two assessments, not that they could be made to work and they are great, are assessing two separate things. The work capability assessment, as the name stands, is assessing your ability to engage with work. PIP is assessing your extra costs. Those two experiences are different. We would want to have disabled people co-producing the assessment process appropriately and not doing the thing that happens a lot in government of asking disabled people, “How can we make these cuts better?” I cannot remember who it was; it might have been Rick Burgess from Greater Manchester. On my first day at DRUK, I met him and he said, “You can’t co-produce austerity. You can’t co-produce cuts,” because you are asking disabled people to be put in that position. How do you do that? With assessment, the problem is that from top to bottom in both of these systems your assessor is trying to find a way not to give you support. That is the pressure that they feel, either formally or informally. In our research at Durham, we spoke off the record to quite a few assessors to understand what it is like. A lot of them told us either that they felt a bit like not even a neutral arbiter but like they knew more about disability than the claimant did or that, because they had someone above them, that decision maker that the DWP talks about, this human backstop, they could be harsher. It was like, “I can be strict here because someone above me, if I get it wrong, will make the decision. It’s not me.” That is a fundamentally flawed process on both of these because it is not asking disabled people, “How are you experiencing disability impairment, long-term health condition as it regards work or as it regards your additional costs?” You are asking, “How can you put yourself in these boxes that we can assess?”

Could I quickly add to that? The assessment process needs to factor in the real world of work and the reality of someone with their particular support needs and access needs being able to find a job. We have the extra component because the standard rate, although it is great it has been raised, is not enough to live on. It leaves you at destitution levels. If you do not have any long-term prospects of a job, you are not able to survive on that amount and, therefore, need the additional component. Functionally, or even according to diagnosis, a person may be able to work, but in the real world they cannot and, therefore, they need that extra component.

Thank you so much, everybody. This has been an informative panel. We have concluded our questions now. We will take a short break.   Witnesses: David Finch, Professor Ben Barr, Dr Lucy Foulkes and David Berry.

A warm welcome back to the pathways to work inquiry. We welcome our second panel today, which includes David Finch, who guested last week as well—it is nice to see you again, David—and Ben Barr. In the interests of transparency, I should mention that Ben and I used to work in the same department together. We also have Dr Lucy Foulkes, and David Berry from Manchester. Would you like to introduce the departments and the organisations that you represent, starting with you, David?

I am David Berry. I am work and skills lead at Manchester city council. I am experienced in commissioning, designing and delivering employability programmes.

I am David Finch, assistant director in the healthy lives directorate at the Health Foundation.

I am Ben Barr. I am professor in applied public health at the University of Liverpool.

I am Lucy Foulkes. I am a research fellow in the department of experimental psychology at University of Oxford.

Thank you. As I say, a warm welcome to you all. We all have some questions for you, and I will kick off. I wondered if you could describe what we know about the health status of working-age people at the moment and what is driving that. Who would like to start?

I can talk about mental health only. I do not know if you have some broader points about health.

Shall I start a bit broader and then you come in?

Yes.

We have been finding that the health of the working age population is getting worse on various measures over the last decade or so, predating the pandemic. One measure that is particularly relevant for this discussion is people with work-limiting health conditions. That has been increasing, as well as people reporting that they have a long-term health condition. Some of that data is from the Labour Force Survey but we also see similar patterns across multiple surveys and we see some of that within diagnosis data as well that we can derive from GPs and prescription data. Mental health conditions have been rising quickly, particularly for younger people. I will not go into too much detail because people will talk about that a little bit more. Although there have been some questions picked up slightly in the last session about why that mental health has been worsening and whether it is actual worsening of mental health, we do see it reflected in mortality rates. They are higher now than they were in the four years before the pandemic. Some analysis of recent work we funded with the IFS showed that. It is particularly due to deaths of despair, which are linked back to mental health conditions. A fairly broad amount of evidence shows that health in general has been worsening. Although a lot of the discussion tends to be about people who are out of work, it is increasing for people in work as well. Broadly, about the same number of people are in work with a work-limiting health condition now as are out of work. For us, the real concern, if we are thinking about employment and people’s health deteriorating once they leave work, is focusing on people who are in work and their health as much as worrying about people who are already out of work and their health conditions.

Do you want to carry on, Ben?

Yes. It is important to recognise how bad trends in public health have been for the last decade. From around 2012, basically, improvements in life expectancy stalled and we have seen virtually no improvements since then. Of course, that was exacerbated by the pandemic but, importantly, those trends in life expectancy have not been equal across the country and we have seen a massive widening of inequalities. In 2023, the life expectancy was still three years below what it would have been if the pre-2012 trends had continued, and we see this widening gap in life expectancy and mortality between richer and poorer areas. The reasons behind that are multiple. One key factor has been the cuts in public services and, in part, welfare reforms that have happened during that time. We have published evidence showing how cuts to local government led to declines in life expectancy. We see that particularly across the deaths of despair that we have already heard about and increases in suicide, but also a reduction in improvements in cardiovascular disease, particularly linked to increases in diabetes and obesity. As we have already heard, we have also seen during this time this deterioration in mental health but, importantly, that deterioration has happened together with widening inequalities. That does not seem to be fully explained by increases in ascertainment, as people say, because even when we look at survey data, we see that the mental health symptoms that people are reporting have increased and those gaps have widened. The increase in inequality is particularly relevant for the issues that this Committee is looking at because that basically means that poor health is becoming increasingly concentrated in places with weaker labour markets, fewer good jobs, much more financial stress and increasing levels of poverty. That concentration of poor health in places with other multiple disadvantages particularly drives this increase in people needing support through the disability benefit systems.

I agree. Focusing specifically on mental health, my area of expertise is focused most on adolescents, 10 to 24-year-olds, but their mental health relative to previous generations is worse just about everywhere you measure it. Whether you get self-reported data in from cohort surveys or whether you ask their parents in cohort surveys, or you ask how many people are going to the GP or how many GPs are recording a diagnosis for them, on all those metrics things are getting worse almost year on year for the past 10 or 15 years. It is relevant that most of the time we measure mental health by asking people to report on their own mental health. That is relevant for understanding why it is increasing, and I can talk more about that. There are lots of legitimate reasons why the problem itself is getting worse, but there are also possibly changes in reporting. Those two are pitted against each other so you have to pick one. It is probably a bit of both happening.

I want to ask a little bit more about the data and what you are seeing about people who are in work and people who are out of work. I know, Professor Barr, you talked about inequalities and the disparities perhaps geographically, but do people who are in work across the mental and physical health spectrum generally display better levels of physical and mental health compared with people out of work? The premise of the Green Paper is all about putting down the barriers that might come up against people who are trying to get into work. Could you explain the disparities there? Also, for people in work, are there different types of work? We talk about good work. Perhaps you might tell us about what that is and how we perhaps can try to encourage that good work and what demonstrable benefits that has for health. That is quite a lot. I do not know if David wants to go first.

We have to look at helping people to manage conditions. Good quality employment support, good work being good for health, can help people to manage their conditions. It is rare that an employment support service would be able to support somebody to become healthier to the point where they are not having to manage that condition. That is one key thing that we are looking at. The prevention approach means that people can avoid developing co-issues such as mental health conditions if they are experiencing something like a musculoskeletal condition at the start. That is why we are trying to intervene early to prevent those issues from becoming worse. That is perhaps the start of the conversation. It is very much around prevention. If you catch people at a later point and support them then, it is about helping them to manage their condition and find work if it is accessible to them. That will help them in very much a person-led way to support them with that condition.

It is such a good question about whether people’s health is better in work or not. Partly the surveys we have access to tell us about this. You have a work limiting or not condition and then a condition underneath it. You do not get severity. I suppose we would think that if someone is reporting a similar condition but is not able to work, it would suggest that people out of work have a more severe condition, but that will probably not always be true about labour market opportunities as well. Some other work we funded as well with the Learning and Work Institute points towards it being about the types of work that are available in different areas that people can do, which would play a different role. The duration that people may have been out of work will also compound some of the health conditions. It is not purely about the health condition. These things will change over time and potentially will be worse. People may have started from a similar position but then had some different paths from that point. On the quality of work, good evidence shows that people’s health can be made worse if the work is wrong than if they remain unemployed, if it is poor-quality work. The quality of the work is important. A lot of discussions will tend to focus on insecurity, zero-hours contracts and that employment, but it is also important that people have control within their work. Autonomy and control are key elements in the work that people do. You can have lower-paid work that provides some of those things as well as stability and structure in day-to-day life, so it is not purely about everyone getting high-paid jobs; it is about making sure that the jobs are available and provide the appropriate levels of structure, stability and security for people when they are moving into work. Finally, we have tended to notice particularly that some of the areas where you get, I suppose, more pressure on people’s health for people who are in work at the moment have tended to be in some public service areas, places like education and the healthcare sector, where the data suggests people are increasingly under strain, I imagine from the resources available. That is playing out in people reporting worse mental health rather than on the physical health side.

Thank you. That is useful.

I will briefly add to the importance of not just looking at averages and saying yes to this idea of good work because it is not meaningful to say whether work is good or bad. It is the same with education. On average, it is probably better to be in school, but school is incredibly stressful for some young people and is the source of their problems. It is great to hear the idea that you are distinguishing. You might be able to predict characteristics that dictate whether a job is good or not and I suppose that varies massively depending on the nature of the job, the nature of the disability and all sorts of factors.

The relationship between employment and health is complex. You have people’s health affecting their employment and their employment affecting their health in both directions, some work being good for people’s health and other work potentially damaging. The only thing that I would add is that to support people with health problems into work requires good employment support, but also the geographical pattern of people being out of work for their health is clustered in particular places. It also requires developing economic growth in those places that will be inclusive of those people and develop jobs in those places that will help people with health problems move into those jobs. There is a lot of emphasis on economic growth. We have done some work with Preston, where they had an inclusive economic strategy and found they had a big effect on employment, but their effect on employment of people with disabilities was five times greater than on non-disabled people. Inclusive economic growth strategies have a role as part of strategies to try to improve outcomes for disabled people.

Professor Barr, you mentioned the inequalities in life expectancy and how they are clustered in particular areas. Does that reflect the pattern of healthy life expectancy as well?

Yes, broadly, those two things are connected, and in fact the gap in healthy life expectancy is even greater than the gap in life expectancy. People are not only dying sooner but are developing health problems earlier in the life course. That is a particular issue where a policy looks at arbitrary age cut-offs, for example, in the proposals. That will mean that people in more disadvantaged circumstances will be more affected by those policies because they will develop those health conditions earlier in the life course.

Professor Barr, I will stick with you for this question. I am conscious that you have done a great deal of research on some of the areas that we are looking at today and previous changes to welfare. Can I ask for your assessment of the impact that previous welfare changes have had on the health of those who are affected?

Sure. To understand the impact these reforms might have, we can look back at what we found in previous reforms. We have looked at a couple of other similar policies. The first one was between 2010 and 2013, with the introduction of the work capability assessment. The Government implemented a programme of reassessing the eligibility of people who were previously on the incapacity benefit and using the work capability assessment. If they were found fit for work through that process, they were moved off the employment support allowance. That was a large policy. Over 1 million people were put through that reassessment process over a relatively short period of time. It was rolled out in a staggered fashion across the country. We used that to then look at the effect that had on mental health and employment. We could see quite clearly that people being put through that reassessment process in an area led to an increase in suicide, mental health problems and prescribing of antidepressants. That was not explained by any other changes in those areas that we looked at. We estimated that that policy in itself led to an additional 600 suicides, 300,000 additional cases of mental health problems and the prescribing of about 700,000 additional antidepressants. We were also able then to look at the effects on employment. A lot of people have been talking about how these changes can increase incentives to work and improve employment prospects, but we found that that policy was not associated with any increase in people with disabilities moving into employment. We did find some shift of people within the Labour Force Survey moving from saying that they were out of work because of their health to saying that they were unemployed and looking for work, but no actual movement of people into employment. That was also supported by the assessment from the OBR that that policy did not release the fiscal savings that was hoped and largely shifted people from disability benefits on to unemployment benefits, and many people potentially then recircled back into claiming disability benefits. We have also completed a study looking at the 2017 change in the employment support allowance, where the rate for the work-related activity group was reduced by about 28% to make it the same level as the jobseeker’s allowance. In that, we have used some representative survey data to look at comparing people who were affected by that policy before and after the policy compared with a group of people who were not affected by it. We also found that that seemed to lead to an increased incidence of depression and increasing movements of people into poverty. We found that that did not have an impact on employment. We have also reviewed international evidence. We have made systematic reviews of the international evidence about similar policies that have been implemented across OECD countries, looking at whether restricting access to disability benefits improved the employment of people with disabilities. The majority of studies that we looked at of the 17 policies did not find any effect on employment of restricting access to disability benefits. There isn’t the evidence to show that removing benefits or restricting access to those benefits gives a benefit in terms of employment.

I appreciate that. Building on it slightly, given the scale of the work that you have clearly carried out, and internationally as well, in terms specifically of getting people into work, have examples of reforms to welfare been successful in getting people into work and reducing the benefit bill?

As was mentioned in the previous session, trying to improve employment of people with disabilities is a complicated issue. It cannot be solved just by making changes to the welfare system. There is good evidence for the employment support approaches that are effective. We have done some reviews of international evidence around this. The key component is co-ordination, bringing together the health sector with the welfare and employment support sector and employers. At the moment, those services are fragmented for people who are out of work. The problem of integration between health and employment support has never been solved effectively. There is some potential where that is more devolved. There is more flexibility for bringing in that integrated support. Some things in Manchester potentially provide some evidence for that. There also needs to be cross-governmental strategies. You need strategies that address these issues of rising health inequalities and that address the unequal economic growth that we have as well as focusing on supporting disabled people into work.

The word “abandoned” in the Green Paper was apt. The employment system has not had the right chance or the right opportunity to deliver some of the change that we are trying to talk about. Integration is key. We often hear the words “hard to reach” used about people, but it is really “failed to reach”. The services are not designed in a way that will help people and support them to get back on their journey. It can be more costly to do that, but we have to look at the wider picture. In Manchester, we have integrated health services and our local foundation trust to support people with musculoskeletal conditions to have a conversation with their clinician and move into an employment programme. However, it is voluntary and person-led. The action plan is person-led, and supports the individual who can take it up if they want to. Over time, we would like to encourage more people to take up that conversation. The key thing, which I think has been talked about in previous sessions, is taking away the fear of having a conversation with somebody and the conversation being at the right time, sequenced in the right way for that individual. It is not looking at the conditionality element or having conditionality as a backstop further down the path.

To some extent, Ben has already answered my question about the impact of the Green Paper on employment and health outcomes for people. If anybody feels they need to add to that, it would be helpful. However, I would also like to throw another question out there to Lucy in respect of the health component of Universal Credit, where under-22-year-olds are set to not be able to apply. Drawing on your expertise in the area that you alluded to earlier on, what reflections about the impact on that cohort of youngsters of not being able to qualify for that health component of Universal Credit can you share with the Committee?

What is the logic behind it, do you know? Presumably to save money, right?

One imagines so.

Yes. I think for whoever was talking in the previous session, I do not think it makes sense developmentally. It is a big period of risk for developing mental health problems. Most people who ever develop a mental illness will have done so by the time they are 24. That varies depending on the disorder. Anxiety disorders generally develop in childhood, but lots of other things develop in adolescence. You are potentially cutting off support at a time when people are first experiencing mental illness. It is also an important time for identity development and understanding one’s place in the world and their sense of self-worth. You establish that by looking at how other people are behaving towards you. Purely from a psychological level, it does not make any sense to deprive people of financial support at that age. I suppose the logic might be that if they are living at home their parents can pay for them, but that does not apply to lots of young people, and it does not seem fair. I do not understand the rationale.

You have talked about the rationale. What impact do you fear this could have on that cohort of youngsters? In your professional view, what might the outcomes be?

This is speculating because I do not know, but I imagine there would be an important impact on a sense of hopelessness. If you do not have the opportunities presented to you at that age to develop independence, it is going to affect how you view the future and your place in the world and society. That is the age period when all those things are developing. I imagine that if you remove the opportunity to help them become independent—obviously, that is what you are doing in an ideal world. You do not want them to be on benefits forever, but it is possibly about how you facilitate them to have a meaningful job and develop mastery and autonomy and all those good things about work. I imagine if you remove that, you are sending a bad message about how valued they are and what their contribution to society would be. Those things can have an impact on a sense of hopelessness and all sorts of mental health problems. That would be my prediction.

I am just going to bring in a point from the initial question. Unless the design of employment support radically changes, we will always see similar outcomes. We have touched on how local design is important because you are making the best use out of the system, and that can also bring in local delivery. Much of the employment support that is delivered is delivered by large organisations, multinational and national organisations, which do a good job, but there is also a place in there for grassroots organisations that might be able to build up more trusted relationships with individuals and may also have an existing relationship with those individuals to help them come through the system. Without multi-year sustainability around some of that provision, you are always going to see this environment that we are in at the moment, which is chop and change. Many employment support services are paid in arrears, which cuts out a large number of providers, because VCSE organisations cannot operate in an environment where they have to wait three or six months before their first payment. Therefore, you are taking out a huge part of the system of support for people with health conditions.

You spoke earlier about the proposal to introduce a new targeted, contribution-based employment insurance. Can you tell us more about it and your views about it?

Yes. I can frame it in a broader sense as well, because I think it is a part of what could potentially be a useful and helpful reform. It is a matter of recognising the types of employment support and where we are on employment policy for people with health conditions or disability, and probably how far away we are from having a cohesive system that fits together and works well. I know there was a question earlier about effective employment support, but I think some of those measures often happen within the wider context. To some extent, you can draw a parallel with something like maternal employment, where there have been some big improvements over the last couple of decades, and a bit longer. That has linked back, I suppose, to various different changes. Some of that is about people’s legal entitlements to return to work. Some of it is about more childcare support and, within the welfare system particularly, some of it is to do with finding people at a point at which you may think they are more able to go back to work—say, using the age of the youngest child for single parents—and within that, providing appropriate financial incentives to make it worthwhile to go back to work. A lot of those things are often missing, in a cohesive sense, for the group we are talking about. One point to recognise is that you need these broader changes to come through. Where the contributory benefit fits in, and one thing we are particularly concerned about, is how, if you have a health condition, your health starts to deteriorate at work and you leave but often do not get any help for several months. Often, by that point, it is too late. If your health condition is bad enough, you go into the part of Universal Credit where you do not get practical support to go back to work. There was talk earlier about the extent to which financial incentives stop people from working. From our perspective, statutory sick pay is inadequate. Many people do not get it paid for very long and can move quickly to the benefit system instead. At that point, a person may go six months or so without getting help with their health condition. The longer they are out of work, the less likely they are to return, particularly if they have a long-term health condition. That can also have a reinforcing effect on the severity of the health condition. The contributory benefit could come to provide a higher level of financial support much more quickly. We think it would be more beneficial if it were framed as being closer to something like the furlough scheme, where you are maintaining labour market attachment so that people do not feel they have left work. You are effectively trying to keep them close to the labour market. People would also need to have some quite effective practical support with it. Part of our concern about the extra investment in employment support is that it is all framed as people being out of work already. It could be more cost-effective to catch people earlier. If they have the right practical and financial support, you can keep them close to the labour market, and it is easier to keep them in work.

Before we move on, can I ask you, Ben, if, based on your evidence from previous work that you have done, you have been able to estimate the potential impacts of the changes in eligibility of PIP and of UC health component?

We have not been able to quantify that. However, we can see from previous examples that it is very likely, and is almost guaranteed, that it will increase poverty for people with disabilities and that will have a negative effect on health outcomes.

I cannot remember the size of the cohort.

These reforms are bigger than previously—

In 2017.

Yes, about three times the size of what happened in the 2017 reform. Large numbers will likely be affected, and the impact on health will likely be great. Q72            David Pinto-Duschinsky: Thank you all for your evidence. It is fascinating and very important. I want to focus on mental health. You have touched on rising prevalence. How much has the prevalence of mental health conditions risen over the past decade?

The number varies massively depending on what you are asking, who you are asking and when you are asking, so I probably cannot summarise it as a single percentage, but it has increased year on year. Conversations have been going on for a very long time, even in the early 2000s, about an increase in mental health problems, but any survey you look at that is measuring mental health now relative to three, five, 10 or 15 years ago shows that it is getting worse.

It depends whether you are talking about people who are above the clinical threshold for a certain disorder, and on which disorder you are talking about. It depends on whether you are talking about symptoms. Often, when these things are measured in cohort studies, they are measuring general distress, which is correlated with having a mental disorder but is not necessarily the same thing. It also depends on the age group that you are asking about. I know it is tempting to estimate, but I cannot pick a number that would fairly represent the whole thing.

Looking across different surveys and studies, and with all the caveats—Lucy Foulkes has put it more carefully than I might—it does look as if the number of people reporting mental health conditions, and to some extent the question sets that show whether people have psychological distress, have roughly doubled since around 2010. That also shows up in our health records data about people diagnosed with anxiety and depression and their prescriptions. The numbers for young people have risen much more quickly.

I do not have that to hand.

That depends on the survey too, and covid makes things messy, because some things increased immediately post-covid and then went down again. There is a problem with relying on, for example, antidepressant prescriptions. One study taken between, I think, 2010 and 2018 showed that antidepressant prescriptions have doubled. However, you cannot know if that means that rates of mental health problems have doubled, people are seeking help more readily, or GPs are prescribing them more readily, or a bit of all that. You also cannot conclude what specific disorder might be changing, because antidepressants are given for lots of different reasons. It is not that I do not understand the question; it is that, genuinely, I hesitate to put an exact number on it.

That is the question that I have been trying to answer for about six years. I do not think there is a straightforward way of teasing those three things apart. If rates of general distress or symptoms of mental health problems have increased relative to 10 years ago, it could be because factors that make people’s mental health worse have increased. I can talk about that as a whole group; that is No. 1. No. 2, it could be that factors that are normally protective of mental health have decreased. No. 3, it could be that reporting has changed and, even within reporting, it could be that the problem was always there but that people are more readily admitting to it now. That could make it look as if things are getting worse, but it is actually due to a decrease in stigma, for example. Maybe rates of depression were always high, and it is just that now we are telling people that they are high. The second component of the reporting thing is that people might be over-reporting things that they might not need to report as mental health problems. Some people have jumped on that as a reason to dismiss people who are reporting higher rates of mental health problems. I can describe the things in the first two buckets as potential reasons why things are getting worse and potential reasons for why protective factors are decreasing, but the frustrating thing is that if we see an increase in general distress, mental health problems, people going to their GP or antidepressant prescriptions, or whatever, it is very hard to know which of those things it is, and by far the most likely explanation is that it is a bit of everything.

I am concerned about the survey data that I think was used in the FT article that you talked about, comparing the prevalence in surveys with the prevalence within benefit claims. We had been funding some work with the IFS to look into whether we can see from survey data what is driving some of the trends in disability benefit claims. Probably the main lesson from that is that the surveys are just not very good at picking up the answers. There have been a lot of issues with sample sizes. I am sure you are familiar with the Labour Force Survey. I question the survey that was used in the FT article. We do not see a similar trend in disability benefit claims as we see in the administrative data, which makes it quite hard to believe that the FT article is validly showing what is happening. You do get a similar trend in the Labour Force and Family Resources surveys, pointing towards mental health on fairly broad measures of mental health. We previously talked about mortality rates among working-age people pointing towards acute mental health conditions, but all the reasons that Lucy Foulkes gave make it quite hard to understand how much rates are genuinely worsening and how much we are picking up stuff that was—

What is driving it?

I am taking some of my answer from good work done by the Youth Futures Foundation with the University of Manchester, which is currently trying to answer that question. Researchers have come up with a list of theories, and they are trying to unpick what evidence exists for each of those theories. The current list, the favourite one, is to do with social media and smartphones, covid, worsening economic conditions, changing academic pressures—the idea that young people are under more pressure to perform in a certain way at school now—and changes in healthy behaviours. Possibly it is that people are doing less of the things that are good for mental health, such as exercise or diet. I think that is the extent of the “things that have got worse” bucket. There is climate change as well, and the possibility that there is more anxiety about climate change. What the Youth Futures Foundation and Manchester are doing at the moment is for each of those looking at the evidence that exists that the thing is increasing alongside the increase in mental health problems, but also that there is some causal evidence. It is obviously not enough to just say, “Climate change has increased at the same time that mental health problems have got worse,” or smartphone use. You have to have either longitudinal evidence, randomised control trials or experimental evidence that demonstrates that one thing increasing has some causal relationship on mental health. That is much harder to do. From what they have done so far on several of those options, their answer is that the data is just not there. Theoretically, it makes sense that maybe academic pressure might have contributed to worsening mental health problems, but there is no hard evidence that has demonstrated that causally. The best we have at the moment is that there are a lot of possible contenders. We are probably not ever going to know definitely what the answer is, but it is very unlikely that it is just one thing, and it is certainly unlikely that it is just people over-diagnosing themselves.

Others on the panel can speak better to the welfare and jobs side of it, but across western countries there has been a pattern of mental health problems getting worse. People are trying to unpack to what extent it is real versus being an artefact of increased awareness or a change in reporting. It is not unique to the UK. However, I do not know what other countries are trying to do to understand the causal evidence.

We do see similar trends in mental health in evidence from surveys in other countries across Europe, and with all the same caveats. All I would add is that the important thing is not just deterioration in mental health but the distribution of the mental health problems and the widening of inequalities. It does seem to be particularly stark in the UK, and potentially more than in other countries. For many of those indicators, we see those widening inequalities in mental health, which potentially supports some of the possible causal pathways more than others. It is quite difficult to disentangle those effects, but the clustering of mental health problems in people who have faced other disadvantages has big implications for the rise in the number of disability benefits.

Comparing areas where people have low discretionary incomes and areas with increases in PIP claims suggests that the cost of living crisis is a powerful underlying factor.

We are short on time, so I want to focus on a couple of things. I was involved in a roundtable a couple of months ago with people with lived experience of poor mental health and employers who had supported individuals with mental health conditions to stay in work. I am interested in understanding what work we can do to encourage employers to stick with people who are suffering from mental health conditions because there are many more people with mental health conditions in work than there are out of work. How do we reflect that? What about the changes in the Green Paper about the right to try and the delay, the lag, between somebody starting work and their benefits possibly not being available to them if the job does not work out? Do you think that might have a positive impact? I am interested in your views on the in-work element.

I think we have strong evidence to show that the Good Employment Charter that operates in Greater Manchester is really positive and that employers can see higher retention rates because of the wider support that they are providing. We have to understand that most businesses are micro or small, there are many of them, and working with a high proportion of them to make change is challenging. It would take a significant national effort. We have heard about attitudes and culture this morning, and that needs to come through. There are many good employers out there, but there are also some that struggle to support their employees with health conditions and the level of support is perhaps not quite right as things stand.

I have two quick things. First, it is partly about making sure that you are setting up roles and designing jobs that can help and suit people appropriately. Second is the ability to respond quite quickly when people’s health starts to deteriorate or is affecting their absence. One thing that has come through in the roundtables we have done with employers is their fear of not knowing what they need to do. It speaks to David Berry’s point. A better understanding of what works and the confidence to put those job changes in place is important.

We have quite often seen, and recently in some programmes, that employees may fear speaking to their employer about their condition and what might happen. We have tried to put person-led services in so we can have that conversation, equipping individuals to be able to have that conversation, but the employer has to meet that side of things too. The Green Paper needs to set out more clearly how that support mechanism will come in for employers so they can do their part.

It is good to hear mention of the Good Employment Charter. It started in Oldham 10 years ago.

It is still early days. The programme launched in December, so it is difficult to talk about successes at this early stage, but it is going very well. We have tried to be innovative with WorkWell and do something different. The “Get Britain Working” White Paper sets out that we need a different approach. We are also just about to become a trailblazer area. We are doing a couple of things. We are working in hospitals with clinicians to identify people who need support and then getting that support for them. It is a very simple concept, but we believe we are the first place in the UK to be doing it, and it is going well. MSK physios have bought into the concept, are referring in high numbers, and we are getting people supported. Another key thing locally is GP referrals through a social prescribing approach. The last thing is that we are working with grassroots organisations that can provide culturally appropriate services. One thing that the “Get Britain Working” White Paper, and subsequently the Green Paper, failed to look at is the intersectionality between race, health and unemployment. We have specific services working with black and Asian residents, delivered by culturally appropriate organisations, so we can start to work on some of the elements of trust that need to be built with specific communities so that they can feel comfortable in accessing support and go on to achieve the outcomes and aspirations that they want to achieve.

Devolution is important, but it must be true devolution. We need multi-year agreements so that we are not just working year to year, because that can hinder partnerships, especially when you are trying to do something innovative.

David, you have commented along the way on the changes that the Government are introducing following the Green Paper. Do you see personalised health and employment support as essential before or alongside any cuts in social security support for sick and disabled people?

We have had programmes in Greater Manchester. We have had WorkWell and it has performed strongly. However, it has not made the necessary deep shift in change and outcomes. We are just about to launch a trailblazer. That trailblazer needs to happen quickly and we need to be looking at innovative services. Working in hospitals, we are supporting people who want help now and we are finding them in the right place. We are not failing to reach those people; we are reaching them in the right place. That is the change that must happen quickly, but it can be hampered by a drive to focus too much on collecting data or getting people to sign documentation. I made a point about services earlier. Services need to be designed around what is going to work for the individual. The point is to try to move people into work and get them engaged in the service. At the moment, we are working with one hand behind our back because we have to ask people 30 or 40 questions before we can start. They can explain to us what they need from us. We are collecting too much information from them. A fundamental point is that you will not get the change you need unless you start to redesign services differently around the customer experience, the relational experience and supporting people.

A brief reiteration of the points that have been made to make sure of them: should this happen before or alongside cuts to social security for sick and disabled people?

If you had better employment services before the changes were made, that would be a much more sensible solution because then you would support people before and through the period of change.

Are there any other final points from the panel?

There is constant talk about the cuts to PIP, employment, and more people getting into employment. I do not think there will be very much overlap between the population losing PIP and those who can go back into work. You could have the employment support in place and then try to reduce benefits, but to some extent the PIP is helping people to be able to work in the first place. I do not think you can do one and then cut the other. A more sustainable approach is to deal with underlying issues such as the health of the working-age population.

Thank you so much, everyone. That concludes our questions for this panel.