In England between 2010 and 2013, just over one million recipients of the main out-of-work disability benefit, Employment Support Allowance (ESA) had their eligibility reassessed using a new stringent functional (as opposed to medical) checklist – the Work Capability Assessment.
Doctors, disability rights organisations, mental health chaities and individual campaigners, such as myself, have raised concerns that this has had an adverse effect on the mental health of claimants, but there have been no population level studies exploring the health effects of this or similar policies, until now.
Research, conducted by B Barr, D Taylor-Robinson, D Stuckler, R Loopstra, A Reeves, and M Whitehead, has established a link between the Work Capability Assessment (WCA) and suicide. The research, published in the Journal of Epidemiology and Community Health (which is peer-reviewed,) and carried out by social scientists from a variety of backgrounds, from the universities of Oxford and Liverpool, scrutinised the rates of mental health issues and suicide in different local authorities in England.
The study found that the authorities with a greater number of people undergoing WCAs also have more people reporting mental health problems, more people being prescribed antidepressants, and more people taking their own lives. The research found that every 10,000 assessments led to around six suicides.
For comparison in terms of statistical significance, isotretinoin, an acne medication which was notoriously linked to suicides, is associated with around four extra deaths per 10,000 treatments.
The researchers estimate that for every 10,000 people reassessed, you would expect to see an additional six suicides (95% confidence interval (CI) 2 to 9), an extra 2,700 reports of mental health problems (95% CI 548 to 4,840) and 7,020 extra antidepressants prescriptions (95% CI 3,930 to 10,100). By convention, 95% certainty is considered high enough for researchers to draw conclusions that can be generalised from samples to populations.
There have been more than 1 million assessments since the WCA was introduced, which suggests that there may be more than 600 people who have taken their own lives who would otherwise have not. The researchers say: “Our study provides evidence that the policy in England of reassessing the eligibility of benefit recipients using the WCA may have unintended but serious consequences for population mental health.”
There have been earlier claims and evidence that the Department for Work and Pension’s (DWP) reforms have led to deaths. However, the DWP has persistently refused to release data which would make it possible to assess whether the death rate for people found fit for work is higher than would be expected.
Both the assessment and appeals process itself, which is widely reported to be stressful, and the financial hardship that occurs when people are denied disability benefits, could result in negative health effects. There is good evidence that loss of income, particularly for people already on low incomes, increases the risk of common mental health problems.
People undergoing a WCA are likely to be particularly vulnerable to the adverse mental health consequences of this policy because a very high proportion have a pre-existing mental health problem. Furthermore, those with physical chronic illness are more prone to mental health problems such as reactive depression, and sometimes, forms of depression that are associated with the illness itself.
The research included efforts to rule out other possible causes of suicide – to eliminate potential confounding variables and bias – for example, there is no similar effect found in people over 65, who are not subject to the WCA – and so the results suggest that the link between the WCA and suicide is not due to “confounding” factors, but is most likely causal.
The Department for Work and Pensions has rejected the study’s findings. A spokesperson said in a statement: “This report is wholly misleading, and the authors themselves caution that no conclusions can be drawn about cause and effect.”
However, the DWP have no grounds for their own claim whatsoever. Whilst correlation isn’t quite the same thing as cause and effect, it often strongly hints at a causal link, and as such, warrants further investigation. It certainly ought to raise concern from the DWP and ministers, regarding the negative impact of policy on many of the UK’s most vulnerable citizens.
The association with the WCA and its adverse effects is, after all, more clearly defined than the one between the drug isotretinoin and suicide, and the drug was withdrawn in the US and some European Member States.
In the UK, it is now (as of November last year) prescribed only under strict monitoring conditions, and patients are provided with warnings about the possibility of adverse psychiatric effects. No such warning and monitoring exists regarding the possible adverse psychiatric effects of the WCA. In fact the government have stifled both enquiry into a causal link and discussion of even the possibility there may be such a causal link, despite being presented with much evidence of a strongly indicated correlative association.
Dr Benjamin Barr, one of the researchers from Liverpool University, said that a causal link was likely: “Whilst we cannot prove from our analysis that this is causal, there are various reasons why this is a likely explanation,” he said.
He agreed that a study looking specifically at people who had undergone a WCA would be more precise, but added that the DWP has not released that information.
Dr Barr said: “If the DWP has data on this they should make it openly available to independent analysis.” He added that the DWP has so far chosen not to run a trial of its own into a link between WCAs and suicides.
The researchers found that those local areas where a greater proportion of the population were exposed to the reassessment process experienced a greater increase in three adverse mental health outcomes – suicides, self-reported mental health problems and antidepressant prescribing.
These associations were independent of baseline conditions in the areas, including baseline prevalence of benefit receipt, long-term time trends in these outcomes, economic trends and other characteristics associated with risk of mental ill-health. These increases followed – rather than preceded – the reassessment process.
The report concluded that the study results have important implications for policy. The WCA and reassessment policy was introduced without prior evidence of its potential impact or any plans to evaluate its effects. Given that doctors and other health professional have professional and statutory duties to protect and promote the health of patients and the public, this evidence that the process is potentially harming the recipients of these assessments raises serious ethical issues for those involved.
The Royal College of Psychiatrists has also said the research was of “high quality”, adding that it called into question the wisdom of the Government’s reforms.
Last year, coroner Mary Hassell told the DWP she had concluded that the “trigger” for Michael O’Sullivan’s suicide was his fit for work assessment.
“During the course of the inquest, the evidence revealed matters giving rise to concerns. In my opinion, there is a risk that future deaths will occur unless action is taken,” she wrote in the document, known as a Prevention of Future Deaths or regulation 28 report.
At the inquest, Hassell said O’Sullivan had been suffering from long-term anxiety and depression, “but the intense anxiety which triggered his suicide was caused by his recent assessment by the Department for Work and Pensions [benefits agency] as being fit for work and his view of the likely consequences of that”.
The inquest heard that the DWP assessing doctor, a former orthopaedic surgeon, did not factor in the views of any of the three doctors treating O’Sullivan. The coroner said O’Sullivan was never asked about suicidal thoughts, despite writing them down in a DWP questionnaire.
Previously, the loss or reduction of benefits has been cited by coroners as a factor in deaths and suicides of claimants.
The DWP have so far failed to respond coherently, other than with a denial of a “causal” link.
You can read the full research report here.
It’s not the only time that Conservative austerity policies have been implicated in causing harm to citizens. Nor is it the only time that Conservatives have responded with utter indifference to the disproportionately negative impact of their policies on the poorest people.
A study from Durham University, which looked at over 70 existing research papers, concluded that as a result of unnecessary recession, unemployment, welfare cuts and damaging housing policies, Margaret Thatcher’s legacy includes the unnecessary and unjust premature death of many British citizens, together with a substantial and continuing burden of suffering and loss of wellbeing.
The research shows that there was a massive increase in income inequality under Baroness Thatcher – the richest 0.01 per cent of society had 28 times the mean national average income in 1978 but 70 times the average in 1990, and UK poverty rates went up from 6.7 per cent in 1975 to 12 per cent in 1985. Suicides increased.
Co-author Professor Clare Bambra from the Wolfson Research Institute for Health and Wellbeing at Durham University, commented: “Our paper shows the importance of politics and of the decisions of governments and politicians in driving health inequalities and population health. Advancements in public health will be limited if governments continue to pursue neoliberal economic policies – such as the current welfare state cuts being carried out under the guise of austerity.”
David Cameron’s government has gone much further than Thatcher ever did in cutting essential support and services for protected social groups, such as sick and disabled people, and poorer citizens.
Pictures courtesy of Robert Livingstone