Rishi Sunak, mental health and the ‘sick note culture’

Prime Ministers in a tight spot are tempted to reach for instant get-out-of-jail policies. More often than not bad ones. Occasionally really lousy ones.

Rishi Sunak’s desire to replace GPs with ‘work coaches’ and less qualified health professionals to assess the mental health of people claiming benefits is a stinker.

Under the new proposals GPs will no longer be responsible for issuing fit notes, formerly known as sicknotes. Work Capability Assessments, which are carried out by health professionals who take your medical history, will be scrapped, subsumed into a flawed Personal Independence Payments (PIP) system.

We’ll come to the reasons why these ideas are misguided, unworkable, unfeeling and, as experience has shown, frequently fatal.

It’s a subject I happen to know a bit about. I’ve lived, off and on, with anxiety and depression for much of my life. It’s like having a troublesome lodger who makes your life hell by crashing about in the attic in the middle of the night.

This is not what Sunak calls ‘the everyday challenges and worries of life’: feeling’ low’ or worrying about what olive oil might cost next month. It’s state of being, invisible and incomprehensible to onlookers, where your body refuses do what the mind wants it to. A crippling feeling of weakness or anguish, irrational but overwhelming, like looking into a fairground mirror where everything you experience is painfully distorted.

I’ve been fortunate. I had resources. I was guided through these moments by skilled physicians and a supportive family. Crucially also by a sympathetic employer who understood that I was worth more to them fit, despite taking extended periods of leave, than struggling and slipping closer to the edge.

Mental health conditions are called that for a reason. The clue is in the name. Depression and anxiety are real, complex and verifiable illnesses, like arthritis. They present with a kaleidoscope of symptoms. These need to be winnowed down to something actionable by experienced professionals.

There are 1.9 million people on a waiting list for mental health treatment in England. For them this feels like a slap in the face: another threat from a state with an agenda. It’s the pull-yourself-together, get-over-it mindset that rarely works because, at its core it’s not a listener. If you don’t understand the problem you’re unlikely to arrive at a solution.

The disability welfare bill is big (though not as big as the £69 billion claimed by Sunak). According to the Office of Budget Responsibility disability benefits spending in Great Britain was just under £40 billion in 2023-24, rising to £58.1 billion in 2028-29: around four per cent of total public spending, and two per cent of GDP.

That’s a lot of money for a cash-strapped country struggling with fraying public services and a flat-lining economy following a pandemic, the soaring cost of energy and the Brexit deficit. But it’s less than our eight closest economic neighbours in Europe.

The savings, if any, of nudging a few more people into work are likely to be marginal. The British Medical Association calls it hostile rhetoric. We are in the middle of a cost of living crisis. Yet again those who can least afford it are asked to bail out the state.

Like the austerity policies launched in 2010, this is not sensible housekeeping. It’s ideological focus-group politics. The notion that some of us are strivers and others scroungers, some are weak and some strong, and that this is a constant state, is deeply embedded in the human psyche. And it’s fertile ground for politicians.

This from George Osborne, Tory Chancellor in 2012: “Where is the fairness, we ask, for the shift-worker, leaving home in the dark hours of the early morning, who looks up at the closed blinds of their next door neighbour sleeping off a life on benefits?” Osborne, the political operator, understood that where there are curtain twitchers there are votes.

The assault on the Britain’s burgeoning welfare state began when Thatcherite Peter Lilley in his address to the Conservative party conference in 1992 said he intended to close down “the something for nothing society”. A Tory government he said was “not in the business of subsidising scroungers”.

“The message was clear: many of those on incapacity benefit were cheating the system; they were dishonest, they were scroungers, fakers and frauds,” writes John Pring, founder and editor of Disability News Service . “The government would clamp down on them and ensure support was only available to ‘genuine claimants’.”

Lilley hired John LoCascio, a senior executive of US insurance giant Unum, to advise the government on how to reduce the number of claimants of long-term sickness benefits. A new points-based test pioneered by the US insurance industry was introduced. Once again Britain turned to the US not Europe for answers.

That in turn led to the wholesale outsourcing of medical assessments to private contractors, a move that would eventually have huge ramifications not just for the safety of those seeking benefits but the entire, struggling mental health sector. The consequences have sometimes been devastating.

At the heart of this dysfunctional system is the Department for Work and Pensions, a mammoth bureaucracy whose culture, repeated experience has shown, is defined not by a duty of care for people with disabilities, but a mission to root out the ‘undeserving’ and cut costs. The disabled are a burden. Government as disciplinarian not enabler.

As far back as 2001 the National Audit Office highlighted “serious problems” with the quality of assessments for work, a gruelling process highly vulnerable seeking benefits are required to go through.  A 2015 study funded by the Department of Health concluded that the programme to reassess people on incapacity benefit using the work capability assessment was linked to nearly 600 suicides in just three years.

More recently in 2020 the National Audit Office (NAO) said that in the previous six years at least 69 suicides were plausibly linked to DWP assessment procedures.  This is not random.  These are not isolated, tragic exceptions. There’s a demonstrable pattern of cause and effect here that persists to this day.

There are scores, hundreds, of individual cases. Philippa Day was a severely mentally ill young mother. The 2021 inquest into her death found that she had deliberately overdosed after the removal of her disability benefits. She was left destitute, trapped in a months-long state of high anxiety and haunted by suicidal thoughts.

Contracts worth around £3bn to deliver “functional health assessments” have now been awarded to a number of large corporations; Capita, Serco, Ingeus UK, Maximus, companies with a strictly limited sense of public duty and a dubious record of delivering what they’re paid for.

Another huge change would end appeals against work placement assessment decisions. There would be a clear loss of judicial oversight and far fewer chances for rights to be clarified under case law – the citizen’s ultimate resort to justice. Executive overreach is this government’s signature impulse.

Supporting people who are, for whatever reason, on their uppers is expensive. But it’s also the mark of a civilised society. Encouraging people to take responsibility for their lives is important. But to work that needs to be a collaborative not a punitive process.

New ways have to be found to balance the books without abandoning people with complex needs. In a perfect world, if people can work they should. Work or being active takes your mind away from dark days (and nights) of the soul. And its good for the economy. No arguments there.

But sometimes you just can’t work. The very thought of work is overwhelming. This isn’t re-entry blues after a holiday or shirking. It’s an extreme, sapping, irrational fear of being in a place that makes demands of you that you can’t meet for reasons you don’t fully understand. After one serious episode I was tempted by some great job offers. But the connection between my brain and my motor functions had snapped like a broken drive belt.

Sunak’s latest policy is a pointless assault on the disabled by a desperate government casting around for votes ahead of an election it’s going to lose. It’s part of the culture wars.

Last word to Tory MP Nigel Mills in recent comments to the Commons Work and Pensions Committee. “My experience of constituents is they don’t generally have a great deal of time or regard for their work capability assessment medical professional.”

He added: “The idea that I’m going to trust a work coach and share my biggest issues and concerns and seek their support and want their counselling if they’ve just told me I’m not getting the extra benefit is extraordinarily unlikely, isn’t it?

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