The UK suffers from stark health inequalities, and disability benefit cuts will make them worse

In the UK, good health is not shared around equally. How many years someone might expect to remain free of conditions that limit their ability to live a full and active life depends on a lot of different things. Whilst good luck and healthy habits play a role, we know that when it comes to health, money matters. The experience of health inequality in the UK is some of the worst in Western Europe, with an average gap of 19 years in healthy life expectancy between the most and least deprived areas. The causes of these gaps are varied and complex, but there is little doubt that they are made worse by the experience of the kind of deep poverty that has been on the rise in recent years. 

At Citizens Advice, we help thousands of people every day on a huge range of issues. From offering help with employment, benefits, housing problems or just dealing with the consequences of poverty, we see the ways in which the challenges of life in England and Wales today can harm people’s health. Since the Marmot review - ‘Fair Society, Healthy Lives’ - was published in 2010, the worsening impact of poverty, inequality and poor policy on health outcomes has been undeniable. Each subsequent government has failed to act to close the health gap, and health inequalities are widening as a result.

The incoming Labour government brought with them a new hope, as they promised to meet the target of halving health inequalities between regions over the course of the parliament. In the context of the UK’s entrenched inequalities, commitments at the regional level are unambitious, but still welcome. But even this limited commitment risked being undone if the consequences of their proposed cuts to disability and incapacity benefits are allowed to play out. The recent green paper on disability benefit reform is set to impose substantial cuts to the incomes of working age adults with a disability or long term health condition, driven not by what’s best for disabled people, but by a political agenda of cutting welfare spending to meet a moving fiscal target. 

We have been at the forefront of tracking and tackling the cost of living crisis that continues to bite. Through the insights of our advisers around the country we have highlighted the impacts this has had across every aspect of people’s lives. Our new project, funded by the Health Foundation, builds on this work to show how these issues are driving health inequalities, pushing people into ill-health or stopping them from living healthy lives. Over the course of the project, we will be looking into how worsening poverty and the deepening housing crisis are harming the health of our clients. But the focus of our first report will be the relationship between work and health, currently the subject of intense debate as the government advances their disability benefits reform bill. 

Disability benefit reforms: one step forward, two steps back

The recent Pathways to Work green paper sets out the government's proposed reforms to disability and incapacity benefits. The government has argued that the growing caseload means that reform is necessary. It’s true that the number of people receiving Personal Independence Payments (PIP) is growing, and at Citizens Advice we are helping more people every month navigate the system (see fig. 1). This is driven by a lot more than just people’s relationship to work, and it reflects worsening health across the working age population. Yet in setting out these changes, Liz Kendall emphasised the government’s ostensible aim to help more people who are disabled or have long-term health conditions into work.

Source: DWP Stat X-plore and Citizens Advice client data

In itself this is no bad thing, and there is plenty to like in the details of some of the policies announced. We know that 1 in 5 people who are currently economically inactive want to work, and that good jobs are good for people’s health. Successful policy in this area could be a win all round, lowering the benefits bill whilst increasing income levels and improving health outcomes for those with disabilities or long term health conditions. Increasing the work allowance, and reducing the need for reassessment when entering employment, will make it easier for people with disabilities or health conditions to work without having to worry about losing access to their benefits. The investment of £1 billion in an employment, health and skills support package aims to address barriers to employment by providing tailored support and improved access to training and skill development which, all else being equal, should help more people find and keep meaningful jobs. Yet taken as a whole, the reforms are likely to harm the income, health and employment prospects of those currently relying on disability and incapacity benefits. 

The scope of the reforms shows that their purpose goes beyond helping people back to work, to instead providing extra fiscal space to a chancellor boxed-in by fiscal rules. Many of the changes impact the Personal Independence Payment (PIP), a non-means-tested benefit that is payable to claimants regardless of their work status. The threshold for PIP eligibility will be raised, meaning that over a million people could lose access to PIP and the other benefits and support services for which it acts as a passport. With the proposed removal of the Work Capability Assessment, eligibility for health related benefits is to be determined by the PIP assessment alone. The government's claim is that this will be partly compensated by an increase in the standard element, but the reality is it will still mean a significant reduction in the support received by people who are unable to work because of a disability or health condition. 

Risking more harm than good 

Any positive impact of policy change is likely to be overwhelmed by the negative consequences of the cuts to the level of support announced alongside these reforms. PIP payments help people meet the higher costs they face because of their disabilities or health conditions, and have played a key role in keeping many in this group above the waterline of a negative budget. The changes will also expose many more people to the risks of conditionality and sanctions under the new system, as significantly more claimants will now be required to look for work as a condition of their benefits. Taking away this support will only make it harder for people to find work. We know that for the people we help, a low income is frequently a barrier to finding appropriate work, particularly for people with disabilities or health conditions that may mean they face additional costs around things like transport.

The impact of these cuts on health inequalities will be stark. The nature of these benefits - and the complex evidence required to claim them - means they support people with disabilities or health conditions that significantly limit their ability to do everyday things most non-disabled people take for granted. Removing this vital income from this group risks deepening those challenges, leading to poorer health and economic outcomes. Exposing more people to conditionality, meanwhile, risks intensifying something that has already been identified as worsening health inequalities. The stress and insecurity inherent in the benefit system can leave an indelible mark on the health of those who have to rely on it. The story of Andrew (names have been changed) below is one of many that highlight the risks of exposing people struggling with their health to the burden of conditionality.

Andrew* is 34 and lives on the South coast with his mum and brother. He suffers from anxiety and depression that means he is currently unable to work, although he is not currently eligible for any health related benefits so only receives the standard element of Universal Credit. Because of his anxiety, he often struggles with forgetfulness, which meant that he failed to attend one of his mandatory appointments. He was sanctioned for missing the appointment, and further sanctioned for failing to take appropriate action despite having contacted Universal Credit as soon as he’d realised his mistake. This left him without money for a month, and served to only worsen the anxiety that was stopping him from working.

Employers have a role to play too

There is also a lot more that the world of work needs to do before everyone who wants to work but currently finds themselves shut out of employment can find good work. Almost 6000 people came to us last year to talk about their experience of health related discrimination in the workplace. In too many cases, firms are failing to make reasonable adjustments for their staff, meaning people are unable to stay in jobs where they could perform well with the right support. The impact of this is not felt evenly, as there is significant variation in the kinds of adjustments available to workers in different roles. One of the most common requests is for increased flexibility and home-based working, but access to this varies significantly, depending on type of work or employer.

The fact that people can now work from home in a range of jobs has been highlighted as one way that the door of employment can be opened up to more people, but this both overstates the number of roles where this is possible and overlooks the fact that its benefits are too concentrated in relatively high paid sectors. Getting adjustments made at work is difficult, with polling showing that only 10% of disabled workers found it easy to get the adjustments they needed, whilst only 18% felt that their employers had removed all the barriers to work they faced.

Despite the positive changes pursued by the new government, more will need to be done to ensure workplaces are no longer unreliable and unpredictable in the support they are able to provide for different health conditions. Until then, leaving people to rely on employers to support themselves will deepen health inequalities.

Poverty and work

Even if the work had been done to ensure that employers and workplaces were ready to be more accepting of people with disabilities and health conditions, the cut to the level of support they receive would still present a significant additional barrier to work. The principle of disability benefits acknowledges the higher costs that people with disabilities face in doing the things other people might take for granted. This might mean they need to purchase adaptive technology, or that they have to spend more on getting around by public transport. Cuts to this level of support will do little to motivate people back into work. Instead it will create more barriers for people, whether that’s in meeting the costs of looking for jobs, or just managing the challenges of making ends meet on a lower income.

One group who might find this transition particularly hard are those who have worked in physically demanding jobs for many years, but find themselves unable to continue working for health reasons. This group risks facing years of poverty in the gap between health stopping them from working and being able to claim their state pension. Given the prevalence of such forms of work at the lower end of the income distribution and in more deprived regions of the country, such changes threaten to strengthen the relationship between ill health and low income.

It is unfair to ask someone to navigate a job market that can often overlook them, while managing the daily reality of poor health - and to do it all with less financial support than ever before.  We have shown how the existing support provided by work coaches too rarely takes account of people’s health or disabilities, forcing people to apply for inappropriate roles at threat of sanction, and providing little additional training or support. For many, it’s not a question of choosing work over welfare, but of somehow surviving a system that seems to be withdrawing compassion and help when it’s needed most. 

Poverty harms health

The wider support to get people into work is welcome. But it will take time for the benefits of these policies to be felt throughout the system, whilst the cuts to people’s income will be felt immediately. The impact of this will fall the hardest on those least able to bear it. We know that for a lot of people, PIP and/or the UC health element are the only things keeping their incomes above the water line of a negative budget. As a result, these cuts risk pushing more people with disabilities and long-term health conditions into poverty, and deepening the experience of poverty for many people already trapped in it. Forthcoming research from Citizens Advice shows that our debt clients who currently receive the standard daily living rate of PIP would face a negative budget of almost £300 pounds if the PIP cut had been applied. This means more people who are struggling with their health and only just managing to keep their heads above water will have to make desperate choices to make ends meet.

Poverty is one of the strongest and most persistent drivers of poor health. Stripping away vital support won’t just make it harder for people with disabilities and long-term health conditions to access work - it will deepen the already stark health inequalities faced by those from lower socio-economic backgrounds. The government’s assertion that this damage will be offset by more people entering work is a problematic one, especially when the path into employment will remain precarious and unsupported for many disabled people over the long-term.

As we will show over the course of this project, the conditions in which people work and live, as well as their ability to make ends meet in the face of rising costs, are crucial in determining their health. The government is trumpeting their increased investment in the NHS, but this good work risks being undone by short-sighted reforms that will impact the poorest and most vulnerable in the country.

This post is co-authored by Ed Pemberton and Emily Lynn