Published by the British Medical Association (BMA) on 17th June 2012
The government is in the middle of implementing what it describes as the most far-reaching reforms of the UK’s welfare system in 60 years. It says they will slash costs and pressure on the health service, but doctors fear that the opposite is likely and that the consequences for patients will be devastating.
Corunna House might be the official name for the home of the Glasgow Disability Benefits Centre, but to many it is known as Lourdes-because you turn up for your WCA (Work Capability Assessment) thinking you are sick – and come out cured.
This observation, from a Glasgow GP, is taken from a report that describes the impact of welfare reforms and austerity measures on patients, GP practices, and health and social care services.
The document is based on the experiences of family doctors involved with the GPs at the Deep End project, a group of 100 practices serving the most socio-economically deprived areas in Scotland.
As co-author and Glasgow professor of general practice Graham Watt says, it makes for grim reading.
‘The examples illustrate that statistics are people with the tears wiped off,’ he says.
This view is shared by Grampian GP David Bell, who gave evidence on behalf of BMA Scotland to a Scottish Parliament committee set up to scrutinise UK welfare reforms.
‘Inhumane’ saving plan
‘The idea of saving £2bn, say, from the group of people in question seems to be inhumane and unreasonable to us,’ he told the committee last month.
‘We have no concern at all about the simplification of the benefits system. In fact, we welcome that, but it should not happen to the detriment of recipients.’
Although the report is about Scotland, the issues it describes are by no means unique to north of the border. GPs in particular, and staff in health and other public services more widely, say they are feeling the effects of welfare reform, and the situation is made all the more acute by the impact of austerity measures and cuts to public services.
Furthermore, some campaigners warn that things could get even worse when further UK-wide reforms come into force next year.
So what does the UK government hope to achieve with its welfare reform agenda?
And what will be the likely effect upon patients, health services and the country more generally?
Welfare Reform Act
The Welfare Reform Act, which received royal assent on March 8, 2012, is the biggest change to the welfare system in more than 60 years, according to the DWP (Department for Work and Pensions).
Its stated aims are to:
- Get more people into work by ensuring employment always pays
- Protect the most vulnerable in society
- Deliver fairness to those claiming benefits and to the taxpayer.
Its main elements include;
- A universal credit, which is intended to provide a single, streamlined benefit
- A tougher approach to reducing fraud and error
- A ‘claimant commitment’, which people must sign to show they understand what is expected of them in terms of job-seeking, but that also protects those in greatest need; the introduction of the PIP (personal independence payment) ‘to meet the needs of disabled people today’.
This follows other welfare changes, such as the introduction in 2008 of the WCA, which is used to assess whether people should receive employment and support allowance, which will soon replace incapacity benefit.
Vote to scrap WCA
At the BMA Scottish local medical committees conference in March, and again at the UK LMCs conference in May, GPs voted to scrap the WCA, which is a computer-based assessment administered by the French firm Atos Origin.
They argued that it should be replaced with a more rigorous and safe process that takes into account the needs of long-term sick and disabled patients.
After the May conference, BMA Scottish GPs committee chair Dean Marshall said patients were ‘concerned and confused’ about the assessment. ‘Many are in fear of how they will cope with the removal of, or cuts to, their benefits,’ he said.
‘Evidence seems to suggest that people with serious health conditions are sometimes being declared fit for work. The frequency of successful appeals seems to us to demonstrate the mechanism’s shortcomings.’
Increased GP workloads
Dr Bell told MSPs on the welfare reform committee that the reforms were also having a negative impact on GPs.
He said: ‘It was intended that removal of certification from the general practice part of the medical profession would reduce the workload, but it has done exactly the opposite.
‘It has brought in people who are suffering from anxiety, who have concerns, and who request us to do something about the mess that they have found themselves in on the basis of assessments.
‘The workload reduction has therefore been negative, and the knock-on effect is reduced availability of GPs to the wider range of patients.’
The impact of the WCA on patients and GP practices is graphically described in the GPs at the Deep End report.
But its effects are certainly not confined to Scotland. Inner London GP Paddy Glackin, who is a part-time LMC secretary with London-wide LMCs, says the capital has been hit hard.
‘In London, the population is more diverse and mobile, and doesn’t have the same community support as exists in other parts of Britain,’ he says.
‘Just about all our patients with severe and enduring mental illness have had their benefits stopped at one point. They’ve won on appeal, but it’s destabilising.
‘You have someone who is living independently and keeping reasonably well; then they lose their benefits or their DLA (disability living allowance) and it destabilises them, and has an impact on their physical and mental health.
‘Then they come to us. They come to us for certification because they’ve been told they need certificates for their appeals.’
Staff cuts have taken their toll, too, he adds: ‘Due to cutbacks, our PCT has stopped funding benefits advice officers in the practice. They did tremendous work and really knew their stuff. I used to have a pretty good handle on the benefits system, but now it’s as much a puzzlement to me as it is to patients.’
He doesn’t blame the PCT for this decision. ‘They felt they couldn’t justify funding it when they were laying off staff in other areas,’ he says. But he adds that it has had a knock-on effect on the rest of the primary care team.
Dr Glackin says people with a history of substance misuse are also destabilised by losing their benefits.
He says those affected are often people in their 40s or 50s, who have been stable for some years on methadone programmes and haven’t offended or been in prison, and who are knocked off balance with sometimes devastating effects.
The only winners are private firms, he says: ‘The vast majority [of individuals affected by negative benefits decisions] succeed on appeal, so it causes great upset and makes money for the private companies who are crunching these people through the system — and it’s unnecessary.
‘Attack on the poor’
‘In my view, it’s an attack on the poor. Patients become unwell during the period of their appeals, so we see them more often. They are anxious and scared. What we’re not seeing is people coming off benefits and finding jobs the next day. Quite the opposite; we’re seeing people lose jobs.’
Many fear things will only get worse with the introduction of PIP.
According to an official impact assessment, the switch from DLA to PIP will lead to around half a million fewer claimants and save £2.24bn a year in benefits payments.
The final details have not yet been drawn up, but it is likely that those currently claiming DLA (worth up to £120 per week) will have face-to-face assessments, followed by regular reassessments. Among those likely to be carrying out these is Atos Origin.
The campaign group Disability Rights UK, formed by the merger of the Disability Alliance, the Royal Association for Disability Rights and the National Centre for Independent Living, has serious concerns about the abolition of working-age DLA.
Rush to save
It fears that the full impact on disabled people and the associated costs to the government are being ignored in the rush to save 20 per cent in overall DLA expenditure by 2015/16.
Before the merger, Disability Alliance conducted a survey of DLA recipients and carers; 16 per cent of respondents said they thought they would become more reliant on the NHS as a result of welfare reforms.
‘Despite requests, [the] DWP has not outlined how the government has worked to ensure one department does not act in a silo and ignore costs to the Department of Health budget as a result of DLA plans,’ a Disability Alliance report says. Disability Rights UK estimates that the new assessment process will create direct costs for the NHS.
It says disabled people will have to provide health information for PIP assessments, and most will do this through their GPs. Assuming people needed only one appointment each, this could result in 2.2 million extra GP appointments.
If the 16 per cent who anticipated needing more NHS care had just one further GP appointment each, this would represent around 80,000 extra appointments.
Risk of hospitalisation
In addition, costs could arise as a result of people being hospitalised after losing support.
‘Many disabled people told Disability Alliance that hospitalisation would be required due to an inability to manage health needs (eg, through not being able to afford prescriptions, attend routine appointments, or cover other health-related costs),’ the alliance’s report says.
The report also warns that more discharges could be delayed if there is less support in the community to enable people with complex needs to be cared for safely at home.
Dr Bell told MSPs he was concerned about plans to pay benefits monthly, rather than weekly. He said: ‘In a significant number of families, money management towards the end of the week leads to a choice between heating or eating for perhaps two days.
‘If a family has a monthly income, they will not manage it so that they starve for two days in a week, but rather they will starve for eight days at the end of the month, and we are greatly concerned about that.’
When the Welfare Reform Bill was passed in Westminster, the Scottish Parliament refused it legislative consent.
This means the parliament has to pass separate legislation to ensure that ‘passported benefits’ — a range of Scottish government-controlled benefits such as free school meals and concessionary travel — could continue.
Despite introducing the Welfare Reform (Future Provisions) (Scotland) Bill in May, the Scottish government is clearly still not impressed.
‘We know the current welfare system is fundamentally flawed,’ says Scottish health and well-being secretary Nicola Sturgeon. ‘But the way to fix this is not by targeting the most vulnerable in our society, as these deep and damaging cuts do.’
This view is backed by the evidence in the GPs at the Deep End report, which looks at the combined impact of austerity cuts and welfare changes.
It describes the effects on patients: at one end of the spectrum are those in work but under increasing stress due to cuts; at the other end are those with chronic mental health issues and established physical problems who are now deemed fit for work and who have had their benefits cut.
According to the report, patients are struggling to make ends meet. They also have increasing contact with GPs and psychiatric services, increasing antidepressant/antipsychotic use, and are self-medicating with drugs and alcohol.
Sicker patients obviously add to GPs’ workloads, but the time wasted on administration is having an impact too.
‘Most people appeal the WCA decisions and ask for letters in support of appeals,’ the GPs at the Deep End report says. ‘It impacts on practice time that would otherwise have been spent on health concerns.’
It also affects staff morale, with several practices reporting sadness and frustration among employees, as well as increased stress due to extra workload.
Furthermore, the report outlines the effects on secondary care and support services, such as cuts to patient transport, delayed discharge letters, and addiction workers struggling to do structured work because they are too busy helping patients in crisis.
In addition, the report adds, social work and housing are being hard hit, and there is increasing reliance on the voluntary sector.
Again, these are UK-wide issues — and Dr Glackin for one is witnessing the pain. He says general practice expands to meet demand, but points out that cuts elsewhere in the system are making themselves felt at his practice.
Transfer of work
‘We’re getting chits of paper and Post-it notes from secondary care, asking us to do blood tests between appointments,’ he says. ‘It’s a transfer of work with no resources, but secondary care colleagues are really under pressure too.’
So what can be done? Following the UK LMCs conference vote, the BMA will lobby for the WCA to be scrapped.
And the DWP has said it wants to improve the assessment, which it says was not fit for purpose when originally implemented.
But ministers insist that the reforms will improve the lives of those most in need when they come into effect next year.
Indeed, they say that PIP will ‘focus support to those individuals experiencing the greatest barriers to living an independent life, while making sure that the benefit remains affordable’.
Presumably, time will tell.