Social Inclusion

For many people with mental health problems and those with Learning Disabilities, being socially excluded is a real issue which affects their daily lives.

We have consistently highlighted the importance of social inclusion for people with mental health problems and with Learning Disabilities. 

What RCPsych has done so far

Between 2006-2008 we ran a Scoping Group on Social Inclusion. 

This followed the Equalities Review which stated the aim “to live in a society which provides for each individual to realise his or her own potential to the fullest”. 

This aspiration can inform our view of approaches to mental health services in the twenty-first century.

In 2009 we published a Position Statement, Mental Health and Social Inclusion, Making Psychiatry and Mental Health. Services Fit for the 21st Century (PDF) and in 2010 we published the findings of the Scoping Group: Social Inclusion and Mental Health.

We have continued our work in the area of Social Inclusion. Listen to our Social Inclusion lead Dr Jed Boardman discuss this vital area of work.

What we’re doing now

Our Policy team has two main areas of work related to Social Inclusion:

  • Welfare Reform and Mental Health
  • Employment

Recent government policy on welfare reform and employment:

Other areas of work linked to Social Inclusion are:

For further information please contact Tommy Denning.

The RCPsych has worked on matters related to welfare reform since the introduction of Employment Support Allowance (ESA) in 2008.

The most recent and important changes to social security benefits were brought in under a Welfare Reform Bill introduced to Parliament in February 2011, when the UK Government announced proposals for reforms to the entire structure of the benefits system. This represented the biggest overhaul to the benefits system for very many years. The government aims were to simplify the benefits system, make it less costly to administer and to increase incentives to seek work.

The Bill became law in 2012.  Many of the changes introduced by the Welfare Reform Act 2012 came into effect on 1 April 2013.

The College has continuing concerns about the impact of these changes on people with mental health conditions and those with learning disabilities as they are amongst the most vulnerable members of society. We wish to see a fair benefits system that does not disadvantage people with mental health problems. Our welfare system must protect and support people particularly when they are at their most vulnerable. It should also empower them to lead the lives they wish to lead.

The College has monitored the governments welfare reform proposals by providing expert knowledge and advice.  In doing so we have liaised with other disability organisations in the Disability Benefits Consortium.

This new in and out of work credit integrates six of the main out of work benefits and was introduced in 2013 in one job centre in Ashton-under-Lyne, Greater Manchester.  Full implementation of UC was to be completed by 2017, but it has not yet been completed. It has been criticised for pushing people into poverty and for its implementation costs.

Universal Credit is a new single payment that applies to people who are looking for work or on a low income. It aims to bring together a range of working-age benefits into a single payment.  It replaces the individual payments of:

  • Income-based Jobseeker’s Allowance (JSA)
  • Income-related Employment and Support Allowance (ESA)
  • Income Support
  • Child Tax Credits
  • Working Tax Credits
  • Housing Benefit

Further information

ESA replaced both incapacity benefit (IB) and income support (IS) paid on the grounds of incapacity for new claims from 27 October 2008.

The Welfare Reform Act 2012 introduced some changes to ESA:

  • Contribution-based Employment and Support Allowance was made time limited. Contribution-based ESA is up to 365 days if the claimant is in the Work Related Activity Group or assessment phase. The 365 day time-limit does not include any time spent in the Support Group or the time spent in the assessment phase if they moved from the assessment phase into the Support Group at the start of their claim.
  • The ‘Youth’ provisions for ESA were abolished. The special contribution conditions that allowed some young people to qualify for contribution-based Employment and Support Allowance without paying National Insurance contributions were removed.

Eligibility for ESA is assessed by the Work Capability Assessment (see below). See also Sanctions and Writing clinical evidence for ESA claims.

Further information can be found at:

Personal Independence Payment (PIP) replaced Disability Living Allowance (DLA) from 8 April 2013 for people aged 16 to 64 with a long-term health condition or disability. Assessments for PIP are based on face-face interviews rather than the written submissions that were used for DLA. 

The claimant has to satisfy the daily living and/or mobility activities test. The person must satisfy this test for at least 3 months and be likely to continue to satisfy this test for a period of at least 9 months after the three-month qualifying period

The provision of clinical evidence for people applying for PIP or making an appeal against their PIP decision can be important for many people with mental health conditions and intellectual disabilities

Disability Living Allowance (DLA) is still available for children under the age of 16 to help with the extra costs of looking after a child who has difficulty walking or needs much more looking after than a child of the same age who does not have a disability.

Further information

The government’s intention is that no welfare claimant will receive in total more than the average annual household income after tax and national insurance – estimated in 2013 at £26,000.  This cap began in April 2013.

The benefit cap is a limit on the total amount of benefit a person can get. It applies to most people aged 16 or over who have not reached State Pension age.  It affects people on Housing Benefit and Universal Credit.  The amount of money you can get in benefits before the Benefit Cap applies depends on where you live, if you're single, if you have children in your household who are responsible for.

Further information

The "Bedroom Tax" is the popular term for the change in the Housing Benefit criteria brought in by the Welfare Reform Act 2012.  The Housing Benefit criteria now takes into consideration the number of rooms and the number of people occupying a property and restrict payments to allow for one bedroom per person or per couple.

If there are too many rooms in a rented dwelling for the number of occupants, an "under-occupancy penalty" is applied which reduces the housing benefit payable.  This applies to housing benefit claimants of working age living in council or housing association accommodation from 1 April 2013.

In introducing what has been named the ‘Bedroom Tax’ the government’s aim was to tackle overcrowding and encourage more efficient use of social housing. 

Further information

Since 1st April 2013 Council Tax Benefit has passed into local authority control.  Until then Council Tax Benefit was a single system administered by the Department for Work and Pensions.  Its transfer to local councils has been accompanied by a reduction in funding of 10%.

Further information

For the first time welfare benefits and tax credits did not rise in line with inflation and instead for the three years from April 2013 rose by 1%.  Disability benefits continued to rise with inflation.

The cut off to claim legal aid is a household budget of £32,000 and those earning between £14,000 and £32,000 will have to take a means test.

This was brought in by the 'Legal Aid, Sentencing and Punishment of Offenders Act', which came into force on 1 April 2013.

The Work Capability Assessment was introduced in 2008 and replaced the previous assessment, Personal Capability Assessment (PCA). The WCA is the DWPs process for assessing whether a person is entitled to ESA based on their:

Limited Capability for Work - the extent to which the claimant’s health condition or disability affects their capability for work. 

And their:

Limited Capability for Work-Related Activity - to determine whether the claimant should be placed into the Support Group because the effect of their condition is so severe that it would be unreasonable to expect them to engage in work-related activity.

The process involves the claimant completing an ESA50 questionnaire which asks about their ability to manage everyday tasks.

The claimant may also be asked to attend a face to face assessment with a doctor or nurse contracted by the DWP. The organisation contracted by the DWP to carry out the interviews is Maximus.

Further information

When a person applies for Employment Support Allowance (ESA) or is reassessed for ESA, they go through an assessment process to decide whether they qualify for this benefit.  This process, the Work Capability Assessment (WCA) assesses whether they have limited capability for work.

The claimant will be asked to complete an ESA50 questionnaire and a clinician who knows the patient may be asked to provide some additional clinical evidence.  The claimant may also be asked to attend a face-to-face assessment with a doctor or nurse contracted by the DWP (currently Maximus).  The final decision as to whether the person qualifies for the benefit is made by a DWP decision maker.

Increasingly, the DWP do not ask clinicians directly to provide written evidence (although they do sometimes send an ESA113 form to complete) and the onus is on the claimant to ask a clinician (GP or specialist) to provide this.

For many patients who are in contact with Mental Health Services, their psychiatrist or other practitioner working with them will be approached to provide a report.  This may be done directly by the patient or by a welfare advisor acting on their behalf.  It is important that clinicians provide good quality, clear and accurate evidence that is appropriate for the purposes of assessing their capacity for work.  To help with this we have created some guidance that clinicians may helpful in compiling their reports.  This guidance may be useful for psychiatrists, other mental health professionals and general practitioners.

This is one of two sets of guidance that we have produced for mental health practitioners providing reports for people applying for Social Security benefits (the other is for Personal Independence Payment – PIP) and we would like to receive any comments or suggestions to improve it. We would appreciate any helpful feedback from practitioners and others.

In partnership with Mind, Rethink and the Citizen's Advice Bureau, the College has produced a briefing on the case for a more effective use of existing patient medical evidences to support a WCA -  Guidance for Mental Health Clinicians providing Clinical Evidence for the Work Capability Assessment (WCA).

The provision of Welfare Benefit Advice can have significant implications for Health services. Recent reports highlight the importance of social security for the recovery of people with mental health conditions:

Resources:

People with severe mental illness are at a high risk of experiencing welfare benefit or financial problems, for example they are four times more likely than the general population to experience problem debt.  In addition, people with these problems are at high risk of experiencing a deterioration in their mental health.  These interactions between welfare benefit/financial problems and mental illness may lead to the familiar picture of a downward spiral into crisis.

 It follows that providing advice on welfare problems to people with mental health problems can be beneficial to people and can prevent further deterioration in a person’s condition and life situation.   The report from the Centre for Mental Health report, “Welfare advice for people who use mental health services". Developing the business case”, suggests providing specialist welfare advice for people using secondary mental health services can be good value for money and can cut the cost of health care.

The report is based on a study of the Sheffield Mental Health Citizens Advice Bureau which provides dedicated advice to people with severe mental illness, supporting about 600 people each year.  This is a specialist service that focuses on people with multiple complex problems, requiring expertise in welfare problems and mental illness.

The average cost of the Sheffield CABs advice is about £260 per client.   The report suggests that this small cost is readily offset by the costs of three areas of savings:

  •  Quicker discharge from hospital – average costs of an inpatient stay is £330 per day
  •  Prevention of homelessness – the costs of homelessness to the public sector, including the NHS, are between  £24,000 to £30,000 per day
  • Prevention of relapse.  This reduces immediate stress (short-term benefit) and increases resilience (long-term benefit).  Cost of relapse per episode is over £18,000.

The report includes nine recommendations, including “All providers of secondary mental health services should review how they ensure that service users are given consistent access to effective welfare advice as part of the care pathway”.

 Resources:

The use of sanctions (often referred to a ‘conditionality’) has been a key mechanism in the welfare reforms of successive governments.  They have been a feature of ESA since it was introduced in 2008.  Sanctions can be applied to an ESA claimant in the Work Related Activity Group (WRAG) if they do not abide to the conditions about work focussed activity or work focussed interviews, without ‘good cause’.

For example, failing to attend or take part in a work focussed interview.  These claimants face a reduction in their payments.  The rules regarding sanctions changed in December 2012.

Sanctions can also be applied to people on Job Seekers Allowance (JSA), but official figures regarding these are not broken down into health conditions.

Sanctions and people with mental health problems

Reports show that there has been a formidable rise in the number of people on ESA who have been sanctioned. The number of people receiving a sanction each month rose from 600 in January 2012 to over 4,700 in December 2013.

Official figures show that people with mental health problems are disproportionately sanctioned – 50% of people in the WRAG group have a mental health problem, but they received 60% of the sanctions.

 Possible reasons include:

  • A lack of understanding of mental health throughout the benefits system.
  • The barriers faced by people with mental health conditions are not readily taken into account.
  • The current benefit system is ineffective and inaccurate at assessing claimants and placing them on the appropriate benefit.

A key problem is that the system of conditionality assumes that the threat of reduction or withdrawal of benefits will encourage people to engage in activities. But this assumption is misplaced – many people with mental health problems want to work but are prevented from doing so by the impact of their condition, systemic barriers and a lack of effective employment support.

The use of sanctions is not only ineffective but has a detrimental effect on peoples’ mental health.

Further information:

Unlike assessment for Disability Living Allowance (DLA) which was done as a paper application only, the assessment for Personal Independence Payment (PIP) is usually carried out as a face-to-face assessment by a health professional.

As with Employment and Support Allowance (ESA) assessments people often find these processes distressing and the assessments carried out may not be accurate resulting in claimants not being given the benefits for which they are eligible.

Practitioners may be asked to provide supporting evidence for people making a claim for PIP (or appealing against their decision). The provision of accurate and well-focused evidence can be of considerable value in assisting in the assessment process and ensure that people are not denied the benefits for which they are eligible.

To help with this we have created some guidance that clinicians may helpful in compiling their reports.  This guidance may be useful for psychiatrists, other mental health practitioners and general practitioners and some examples of reports.

The assessments for PIP include a points-based system for judging the applicant’s ability to carry out a range of daily living and mobility activities.

Further information on these activities and descriptors are given in Personal Independence Payment Activities and Descriptors Some (PIP) rules and meanings that relate to the Activities and Descriptors.

This is one of two sets of guidance that we have produced for mental health practitioners providing reports for people applying for Social Security benefits (the other is for Employment and Support Allowance (ESA)) and we would like to receive any comments or suggestions to improve it. We would appreciate any helpful feedback from practitioners and others.

Good work plays a central role in all people’s lives and is generally considered to be beneficial to health and well-being.    In general, people with mental health conditions are less likely to be in employment than those without, particularly those with long-term and severe mental health problems.

Why is employment important?

Work as a social and health benefit

  • Provides a monetary reward – but also non-financial gains, including social identity and status, social contacts and support, a means of structuring and occupying time, it provides activity and involvement and a sense of personal achievement
  • Enhances quality of life
  • Promotes social inclusion, linking the individual to society
  • Unemployment is linked with premature death, development of mental health problems, increased use of mental health services, increased risk of suicide

Work as a rights issue

  • Article 23 of the United Nations Declaration of Human Rights: “everyone has a right to work, to free choice of employment, to just and favourable conditions of work and to protection against unemployment.”
  • Valuing people with disabilities includes promoting respect, self-determination, and empowerment 
  • Prejudice and discrimination is a major obstacle to people with mental health problems gaining work

Work as an economic issue

  • A large proportion of public money is spent on welfare benefits for the unemployed and almost 25% of invalidity payments are paid to people with mental health problems.
  • Further costs to society come in the form of loss of productivity due to absenteeism and presenteeism

We've promoted the value of work for people with mental health problems for many years. In 2002 we produced a Council Report on Employment Opportunities and Psychiatric Disability and this was later reviewed and included in the work of the Scoping Group on Social Inclusion.

In June 2013 we held an Employment roundtable to which experts and stakeholders were invited to discuss and contribute to the future work of the College in this area which resulted in our latest publication on Employment and Mental Health (pdf).

In 2012 a Royal College Special Interest Group (SIG) in Occupational Psychiatry was formed.  This SIG brings together the work of other professional groups including the Faculty of Occupational Medicine, the Society for Occupational Medicine, the Royal College of General Practitioners, organisational and occupational psychologists, employment lawyers, the insurance industry, and HR managers.

Further information

Employment: The economic case - Centre for Mental Health