Focus on the causes, not the symptoms

As we look ahead to the government’s green paper on disability benefits, there is one thing we can — hopefully — all agree on. Disabled people, and people with long-term health problems, deserve the chance to enjoy the same standard of living as people in generally good health. We will never eradicate all inequalities, but we can strive to produce outcomes that are as fair as possible.

Fairness means providing an income to disabled people and people in ill-health to meet health-related costs. For some, it will mean removing the financial necessity of employment, because working would be harmful or indeed impossible. For others, however, it means providing financial support so that they are able to work.

But the benefits system is stuck. It isn’t getting everything completely wrong, but we don’t think it is getting anything completely right either. And more and more people are claiming health-related benefits. Perhaps we can say it’s a good thing that, so far, the system has remained largely intact as demand has grown. But it would be naive to expect this to last.

And we can say with more certainty that the disability benefits system is not good at helping people to exit the system, or indeed at preventing them becoming disabled or unwell in the first place. Maybe this sounds like asking for too much. But it’s the kind of place we need to get to if we are to retain over the long term the things that we really need the benefits system for. We do some of this thinking in this essay, after challenging some of the arguments being used to justify cutting back the current system.

The system in principle and in practice

The disability benefits system for working-age people technically consists of both (universal) disability and (means-tested) incapacity benefits[1]. The main disability benefit in England and Wales is now Personal Independence Payment (PIP)[2]. There are different rates and components of PIP, reflecting the varying effects of a person’s ill-health on their life and the activities for which financial assistance is required.

The main incapacity benefit is provided via the Universal Credit system, generally for people not in work (the Universal Credit route is replacing income-related Employment and Support Allowance (ESA)). A points-based Work Capability Assessment (WCA) determines whether a claimant has Limited Capability for Work (LCW), or Limited Capability for Work and Work-Related Activity (LCWRA) (or neither). People assessed as LCWRA receive an additional Universal Credit award, and have no work-related expectations[3].

Through this structure, it is possible to discern three main aims of the disability benefits system:

• Social insurance: if any one of us were unlucky enough to be unable to provide an income for ourselves through work, the benefits system — mainly financed by the luckier majority, although even people out-of-work pay consumption taxes — would be there to help
• Providing for dignity and independence for disabled people: people would get help so they can perform the everyday tasks that most people take for granted, and worry less about basic living costs, so they can participate in society as fully as possible
• Helping people stay connected to the labour market: indirectly, because benefits like PIP may fund things that make work possible for disabled people and people with long-term health problems, and directly, because the WCA assesses what work-related activity claimants can undertake (as well as, quite rightly, ensuring that some do little or none)

Well, that’s the theory. But let’s be honest, these aims are not always met in practice[4].

People struggle to access the system, and maintain their eligibility. Assessment processes cause stress and anxiety; for many, they don’t feel personalised, supportive or grounded in health expertise. Delays are common.

Assessments are also not one-off processes: many feel they are stuck in a cycle of reassessments. And the wrong outcome is reached far too often — requiring people to appeal decisions to get what they are entitled to.

Samantha* lives with her husband and son in the South West of England. She came to us after an 8 month delay for her PIP review left her in “horrific stress”. She has severe Multiple Sclerosis and relies on her PIP award not only for the money she receives but also for the access it gives her to a Motability vehicle and a Blue Badge for disabled parking. This is a lifeline for Samantha, as she isn’t able to walk very far. Without confirmation of a renewed PIP award, Samantha struggled to renew her Motability vehicle and Blue Badge at the end of the original award period, even though she continues to be eligible. Samantha and her husband had to spend hours writing letters, submitting evidence and trying to contact different people to make sure that her Motability car and Blue Badge would be extended. With her physical condition worsening, this ongoing stress was the last thing she and her family needed.

The system is also struggling to produce decent employment outcomes. Like ESA before, Universal Credit is not good at helping people into part-time work, or jobs suitable for fluctuating conditions. It takes little account of how particular conditions are aligned with the demands of particular jobs, or of accessibility issues around getting into a workplace. People are effectively deemed ‘not ill’ (or ‘not ill enough’), so they are expected to apply for any job available, ‘a little bit ill’, so they don’t have to work but they don’t get any additional financial support, or ‘very ill’, so that they get extra money but are ineligible for any employment support at all.

A flawed benefit conditionality regime exacerbates all of this. The cliff-edge between having no expectation of engaging with job centres, and expectations that are often rigid, impersonal and crudely monitored — accompanied by the threat of sanctions — is very steep. It is understandable that claimants would resist being subject to conditionality; the solution is to transform how conditions are designed and applied, not to move the boundaries so that more people are subject to rules that won’t help.

And above all, the disability benefits system is simply providing too many people with too little money to live on. On average, the disabled people we help with debt who receive Universal Credit already have a £17 shortfall in their budget each month. This means their essential costs, such as food, housing, and care, are £17 more than their monthly income.

This is partly a story about some disabled people not being able to access disability and incapacity benefits. For example, the disabled people we help with debt are 12% more likely to be in a negative budget if they don’t receive PIP (a negative budget is where your monthly income isn’t enough to cover your essential costs). We can already see the impact losing PIP has on the disabled people we help. When our debt clients lose PIP, they cut their spending on health and care by an average of over £200 a month. They also spend an average of £130 less on food each month. Cutting back on these essential costs is likely to lead to worsening health outcomes.

But it’s also a story about benefits being set at a level that does not meet the real cost of living for many. And it is inevitable that disability and incapacity benefits will be used to cover basic living costs — when income-related benefits and housing cost support do not keep pace with rising food or energy prices and the cost of housing[5].

These are the kinds of problems we should be focused on trying to fix. They combine to make the disability benefits system inadequate for many, and this inadequacy often serves to make people more unwell. Sadly, while policy-makers are not unmoved by these issues, the tide of reform seems to be pulling us in another direction.

New government, old ideas?

There has been a tendency in recent years — including among policy-makers, as well as the popular media — to suggest that the disability benefits system is indeed unfair, but that it is unfair not for the people who rely on it, but rather people in good health. Too many people, so the argument goes, are able to ‘sponge’ off the benefits system while the rest of us have to work for a living.

There is a slightly more sober argument that leaves the question of fairness to one side, and says that, whatever the rights and wrongs of the situation, the cost of providing disability and incapacity benefits is now unaffordable.

This brings us to the new government’s disability benefits green paper, which we expect to be published later this month. One way or another — in fact, probably in several different ways — we can expect proposals that mean the financial support currently available to disabled people, and people with long-term health problems, will be scaled back.

We think the government is generally in the ‘it costs too much’ camp rather than the ‘too many spongers’ camp, but they do sometimes lean on the latter in order to justify the spending cuts that seem likely to come.

Alison* is a widow in her early sixties who lives alone. She has a permanent brain injury which causes health issues that limit what she can physically do. Before her illness, Alison ran her own cleaning business. Now she is unable to work and receives Universal Credit and Personal Independence Payment. For several years, she received the additional LCWRA element of Universal Credit for people who are too unwell for employment and was in a positive budget. In 2023, however, her claim was reassessed and she was deemed fit to work. As a result, her monthly income was reduced by around £400. She has appealed the recent decision but while waiting for the tribunal outcome, she cannot make ends meet. “Since my limited capability for work element was taken away, I’m getting £400 a month less, roughly. Now I’m living on a shoestring,” says Alison. “I don’t buy clothes, I have not got the money. I’ve only got £40 to last me for the next 12 days. As soon as you get any money in the bank, you go food shopping and it’s gone. It goes so quick. I have to shop very carefully and I don’t go out.”

There is a bit of history here. The new government has inherited what it sees as a significant problem: the growing number of people claiming disability and incapacity benefits means that the costs of the system are rising.

This is a dilemma that shouldn’t be dismissed. But it is also necessary to point out that the new government has inherited a pre-programmed set of solutions too — reforms that arguably prioritise making the system cost less over making it work better. These include the previous government’s plans to ultimately abolish the WCA, in favour of relying on PIP assessments regarding health conditions, and job centres regarding work capability. Other plans include shorter-term WCA rule changes that would restrict eligibility for LCWRA status, meaning there will be fewer claimants qualifying for this category in future. The new government has indicated it may this agenda forward in both regards[6].

The previous government also made proposals for PIP, including restructuring eligibility and ending regular cash payments. The election prevented any final decisions being taken, but we are expecting the new government’s green paper to resurrect at least some of this agenda.

Beyond the policies, the new government has perhaps also inherited a way of doing things (assessing conditions, monitoring compliance) and seeing things (cost as a success measure, ill-health as burdensome), which shape the kind of policies that are even conceivable. Policy paradigms die hard. And some of this stuff is very longstanding; reinforced the last time the Labour Party was in power, as well as by the specific reforms and proposals of the more recent coalition and Conservative governments.

What we are left with is a familiar set of tools, frequently applied to ‘the welfare problem’:

• Reducing the ‘generosity’ of benefits so that the incentive to claim is lower
• Increasing the burden of receiving benefits by intensifying conditionality
• Making disability benefits more difficult to claim

We don’t yet know what’s in the green paper. But the mood music strongly suggests its primary intent is finding a way to quickly reduce the benefits caseload, rather than to better understand and address why the number of people needing support is growing.

The promise of Get Britain Working

There is, however, a more encouraging agenda coming out of an adjacent DWP policy space. The Get Britain Working white paper outlined a new approach to employment support, where people receive localised and more holistic support, moving beyond the focus on ‘any job’ and compliance with conditionality. When government ministers allude to ‘too many spongers’-type arguments, they are usually making a broader argument about supporting people who can and want to work, but this nuance is downplayed in the media.

Arguments in Get Britain Working about the impersonal nature of the relationship between claimants and job centres chime with Citizens Advice research on work coaches, which found job centres focused on administering benefits and associated rules, rather than providing tailored, high-quality employment support (and access to wider advice). We believe that work capabilities should be developed, not simply assessed.

Olga* has been signed off from her job as a carer whilst she recovers from surgery. Due to the physical nature of her job, her health condition makes it impossible for her to return to work until she’s recovered. She is currently undergoing treatment and her doctor has advised that she should be fit to return to work in another 3 months. However, Olga underwent the WCA and was found fit to work. This means she is now expected to either return to work in a relatively short time, or start looking for a new job. She enjoys working as a carer, and was looking forward to returning once her health improved. However, she now feels she has no choice but to look for another job as she can’t afford to lose support from Universal Credit. Her work coach told her she needed to accept any job, “even deep sea diving”.

Yet the investment is not yet in place to match the government’s ambitions. And there is a danger of the cart being put before the horse, with disability and incapacity benefits being withdrawn before new forms of employment support are available to help people into sustainable jobs. The real sense that job centres will eventually become something more fit for purpose is undermined by the fear that they are in the meantime being readied to onboard those whose LCWRA status (and income) is under threat.

It would be worth examining some of the claims being made in relation to disability and incapacity benefits — albeit not necessarily by the government directly — in advance of the green paper’s publication.

“The cost of disability and incapacity benefits is unaffordable”

It is beyond doubt that more people are successfully claiming health-related benefits (and claimants are slightly more likely to qualify for higher rates of PIP or Universal Credit than, say, before the COVID-19 pandemic). Spending on these benefits has therefore risen, and in the view of the government — and the Office for Budget Responsibility (OBR) — is likely to rise further.

We will explore below why more people are claiming and receiving disability and incapacity benefits. And it is a little beyond our remit to make a judgement on the macroeconomic implications of welfare policy, i.e. the question of whether higher spending will breach limits of what the UK economy can tolerate. However, what we can say is that this claim is not as straightforward as it seems.

Spending on health-related benefits for working-age people and children has risen from around 1.7% in 2009/10 to 2.4% of GDP in 2022/23. However, non-health benefit spending has fallen from 4% in 2010/11 to 2.6% of GDP in 2022/23. Overall, spending as a proportion of GDP is similar to what it has been since the 1980s[7].

Our point is not that the rising cost of the disability benefits system doesn’t matter, but rather that the balance between different forms of welfare spending is a choice. Health-related benefit spending has risen, but not as fast as other areas, and perhaps as a consequence of falling spending in other areas (e.g. as standard allowances in income-related benefits have lost value). And recent increases in spending have only served to bring the UK close to the OECD average, having historically spent less on this area of welfare.

Even if we were to accept that controlling cost is the most important priority for welfare policy, cutting payments and restricting entitlements is not necessarily the way to achieve it. Recent experience suggests that disability benefits reform rarely achieves savings projected at the time of implementation.

“It is too easy to claim disability and incapacity benefits”

This is the big one. The claim has several aspects to it, with different voices amplifying different arguments:

1. Eligibility criteria for disability and incapacity benefits are too wide (especially for people with mental health conditions — discussed in the next section)
2. People are more likely to claim these benefits following ‘income maximisation’ advice, more common now as a result of the cost-of-living crisis
3. The integrated nature of the Universal Credit system makes it easier for people out of work to claim the additional health elements
4. The low value of the Universal Credit standard allowance and non-health elements incentivises people to claim the additional health elements

We have some sympathy with the fourth argument. After too many freezes and below-inflation increases, not to mention policies such as the two child limit, Universal Credit has not kept up with the cost of living in real terms. But there is not actually any evidence that this, rather than their underlying health issues, is the reason people are successfully claiming health-related benefits.

There is a similar lack of evidence around the income maximisation argument. The notion that Universal Credit is better than legacy systems at passporting people into incapacity benefits is more plausible — but this is precisely the kind of seamless support an integrated income-related benefits system was supposed to enable.

Ultimately, it can only be a good thing if people who need health-related benefits for reasons related to their health are now more likely to claim them.

So what are the reasons there are more people who need health-related benefits? It’s a complicated picture, and all stakeholders need to strive to better understand the underlying causes. We explore a few of these below.

To state the obvious: more people are disabled or unwell. The proportion of people reporting a physical or mental health condition or illness that has lasted, or is expected to last, 12 months or more has risen from 19% to 24% in the 10 years from 2012/13 to 2022/23 (it is 23% for working-age people only).

And pressures on the NHS mean we are not addressing rising ill-health particularly well. A NatCen survey of disability and incapacity benefit claimants for DWP found that 41% of respondents were on a waiting list for treatment for their health problems, and 50% who were currently out-of-work felt their ability to work was dependent on receiving treatment.

As suggested above, if the argument that the low level of non-health Universal Credit payments leads to increases in incapacity benefit spending has merit, it is potentially a case of inadequate benefits causing and exacerbating health problems, rather than simply people being incentivised to claim as much as they can get away with. Inadequate benefits are a cause of poverty, and poverty is a cause of ill-health. If you cannot afford a decent home, and sufficient heating and nutritious food — and even if you are simply worrying frequently about money — your health is likely to worsen.

OBR analysis shows that a significant proportion of the rising incapacity benefit caseload results from a higher state pension (so people are receiving for Universal Credit or ESA for longer rather than moving onto the state pension, Pension Credit, and/or pensioner disability benefits), and population ageing (because older people are more likely to be disabled, irrespective of the increasing prevalence of ill-health).

Martin* currently receives the standard rate of the daily living component of PIP. Following a stroke, his level of need has increased, so he came to his local Citizens Advice for help submitting a PIP review form. Despite a high level of need, Martin is likely to receive low points across a range of daily living activities, rather than high points in one or more activities. For example, his adviser expects he will score 2 points for both washing and bathing and managing toilet needs or incontinence, as he requires aids to complete these activities. Despite scoring low points, he has a range of extra costs associated with his health conditions. For example, he can’t prepare meals from scratch himself, so he buys pre-prepared meals, which are significantly more expensive. The time it takes to complete activities like showering also means his utility bills have increased.

Research by the Resolution Foundation finds that PIP is no easier to claim today than when it was introduced, nor easier than previous disability benefits. Evidence from the people we support shows claims processes for disability and incapacity benefits are difficult to navigate and fraught with uncertainty.

“People with mental health conditions are exploiting the benefits system”

What the arguments about disability and incapacity benefits being too easy to claim are really getting at, however, is that some people who might be defined as disabled or ill actually shouldn’t be, i.e. claimants with a mental rather than physical health condition.

As then Work and Pensions Secretary, Mel Stride, said in 2024:

“There is a real risk now that we are labelling the normal ups and downs of human life as medical conditions which then actually serve to hold people back and, ultimately, drive up the benefit bill. If they go to the doctor and say ‘I’m feeling rather down and bluesy’, the doctor will give them on average about seven minutes and then, on ninety-four per cent of occasions, they will be signed off as not fit to carry out any work whatsoever.”

The reality is rather different. Assessments directly and rigorously examine how ‘serious’ a person’s condition is. Somebody simply feeling ‘down and bluesy’ is not going to pass.

WCA caseload data also demonstrates that such claims are, at best, simplistic. DWP reports that 69% of WCA decisions from January 2022 to August 2024 involved ‘mental and behavioural disorders’, yet there are several ways in which this is a misleading statistic. Firstly, this is a very broad category that includes neurodivergent and cognitive conditions as well as conventional mental health problems such as depression and anxiety.

Secondly, unlike ESA, Universal Credit statistics do not report what a claimant’s primary condition is. The data shows us that multiple conditions across physical and mental health conditions are the norm (with the former much more common). There were 1.2 million instances of mental and behavioural disorders among the 1.7 million decisions (this is the origin of the 69% statistic), but there were also 3.3 million physical conditions reported among these decisions.

Thirdly, WCA decisions where a mental and behavioural disorder was recorded resulted in a LCWRA outcome in only 64% of cases — a lower proportion than for virtually every category of physical illness[8].

Andrei* has multiple health conditions, and receives the LCWRA element of Universal Credit. He came to his local Citizens Advice for help completing a PIP application. Andrei has been officially diagnosed with autism and PTSD, but how much he can do daily tasks or move around independently are also affected by other conditions, which haven’t been formally diagnosed — including dyslexia, anxiety, depression, and obsessive-compulsive disorder (OCD). He has been referred to hospital appointments and is undergoing many diagnostic tests for these other conditions, but getting diagnoses is being delayed by long wait times for specialist appointments.

For PIP, we do know what claimants’ main conditions are, and that the ‘psychiatric disorders’ category accounts for 38% of cases. Again, however, this covers a wide range of conditions. It includes ‘mixed anxiety and depressive disorders,’ accounting for only 11% of all PIP cases. And there are separate categories related to anxiety, stress and mood conditions, together accounting for another 7%.

As with physical health, a mental health condition can lead to higher living costs. Citizens Advice’s consumer research has identified a mental health premium for some essential services[9]. It is clear that accessing financial support is vital for people with both mental and physical health problems. When we compare the budgets of the people we help with debt who receive PIP and have either mental or physical health conditions, we see no meaningful difference in the amount people spend on care and health costs, or living costs more generally[10].

“There are jobs that disabled people could be doing”

One of the most frustrating aspects of the discourse around incapacity benefits is that the rise of remote working means the world of work is now far more accessible for disabled people. This rationale was offered in support of the previous government’s plan to reduce the points available for mobility-related descriptors in the WCA (a policy that may be taken forward by the new government).

Analysis by Citizens Advice undertaken at the time of the previous WCA consultation demonstrated that people receiving Universal Credit were far less likely than the workforce in general to be working from home, and that only a tiny proportion of roles then available on the DWP’s own Find a Job service offered remote or hybrid working as an option. Recent analysis by The Big Issue found that, on job collation website Adzuna, only 3% of current listings refer to home or hybrid working.

Even if there were greater remote working availability, we would need to acknowledge that many such roles would still require occasional travel to an office location. And it cannot be assumed that remote working is beneficial or preferable for people with health problems — it can be particularly challenging for people with mental health conditions.

More generally, the Low Pay Commission has consistently reported on the growing intensity of low-paid work, meaning jobs are typically becoming more physically or mentally demanding, with more limited rest time. The impact of this trend on the ability of disabled people who are out-of-work to move into paid employment needs to be further investigated[11].

Disabled people, and people with a long-term health problem, who are economically inactive are more likely to want to work than people who are economically inactive without significant health problems. Their health is the main barrier to doing so. Discrimination is also an issue: 41% of the people who sought our help on employment issues in the last year were disabled or had long-term health problems, but this rises to 58% among people we helped specifically on employment discrimination issues[12].

“Lots of people claiming disability benefits are well-off”

The notion that people receiving disability benefits are well-off lends weight to the suggestion that benefits like PIP should be means-tested. There is very little evidence to support this claim. Of the roughly 3.8 million working-age people receiving PIP (or DLA in a small number of cases) in August 2024 in England and Wales, around 2 million were also receiving an incapacity benefit such as ESA, or were Universal Credit claimants classed as LCW or LCWRA. A further 230,000 receive Universal Credit without health-related aspects. As such, a significant majority of PIP claimants have an income low enough to also receive income-related benefits.

Moreover, it does not follow that the roughly 1.5 million people claiming a disability benefit but not an incapacity benefit are well-off. The need to undertake a WCA, as well as a PIP assessment, will dissuade many from claiming Universal Credit even if their financial circumstances suggest they would be eligible. Some may believe they would only have a small Universal Credit entitlement (perhaps due to a partner’s income) so do not want to subject themselves to another claims process — yet even people with small Universal Credit awards can be considered to have a very low income. And many may have savings close to or beyond £16,000 that would mean they could not claim Universal Credit, or again receive only a small award — this doesn’t mean they don’t have a low income.

As with any universal benefit, some PIP claimants may indeed be relatively well-off. However, firstly, we do not know very much about this group. The NatCen survey for DWP discussed above suggests that ‘just under half’ of PIP claimants who do not also claim incapacity benefit have an equivalised income (ie taking into account the income of other household members) of £15,912 per year or more — the highest level recorded in the survey. £15,912 is hardly a high income. Furthermore, more than a quarter of this group had equivalised income of less than £6,672 — this is an extremely low income.

Towards a preventative agenda?

The disability benefits system needs to be defended against harmful cuts, but this does not mean it is functioning as well as it can. What needs to change?

One thing that doesn’t need to change is the role of the benefits system in protecting disabled people and people with long-term health problems from destitution, and in levelling the playing field for people with significantly higher living costs related to their health. Everyone deserves the same opportunity to live well. This means incapacity benefits within Universal Credit where health issues prohibit paid employment for those without other sources of financial support, and disability benefits like PIP available to all who have to spend more to meaningfully participate in society and live a dignified life.

This basic structure needs to persist, but also needs to be reaffirmed as society evolves and we become aware of new risks to well-being. One of these is mental health. We can argue over whether the rise in the number of people with mental health conditions is a result of better awareness, structural factors that make mental health problems more likely to occur, or the inadequacy of NHS mental health services meaning that conditions persist and worsen. The outcome for people affected is the same. It is a medical reality that the impact on work capability and the risk of destitution is as serious as for many physical health conditions, and the welfare state needs to recognise this rather than retreat.

The welfare state also needs to get better at some of the things it ostensibly already does. First, there needs to be a whole-system approach to helping people into work. This means more and better employment support, more personalisation and flexibility so that people are no longer caught between prolonged inactivity and harmful conditionality, and better incentives so that claimants do not face steep cliff-edges if and when they are able to move into appropriate work.

Second, help with wider living costs needs to be adequate. The link between general working-age benefits and inflation is fragile, and freezing house cost support — as the cost of renting has skyrocketed — has been normalised. Disabled people cannot focus on their health if they are worried about keeping a roof above their heads, and poor quality housing harms health outcomes in a very direst sense.

Ultimately, however, we want a benefits system focused on fixing problems, as well as patching things up. We want to make the case for a new principle for disability and incapacity benefits: prevention.

Health policy has long aimed to ensure health systems prevent medical problems arising or worsening, and the new government has embraced this agenda. What would applying this approach to disability benefits look like?

Well, it depends to some extent on what we’re trying to prevent. The first thing would obviously be poverty, and while the disability benefits system is flawed in this regard, it is clearly focused on this objective.

The second thing would be disengagement from the labour market, what some quite callously label ‘worklessness’. This overlaps with poverty prevention, insofar as paid employment generally leads to a higher income. But preventing worklessness cannot simply mean getting people into any job — a job that might cause harm, a job that might not stick.

Preventing unemployment (and under-employment) is partly about building people’s capabilities. It is partly about keeping people in work, as well as getting them into work. It is also partly about improving their resilience: ensuring they have the right support and infrastructure in place so they can cope with the demands that searching for, obtaining and maintaining employment can place, especially on people with health challenges. In this respect, while preventing worklessness helps to prevent poverty, preventing poverty and its myriad implications is also part of how we prevent worklessness.

And the third thing we’re trying to prevent would be disability and ill-health. Of course, people encountering the disability benefits system already have a long-term health problem. But the benefits system can seek to avoid causing health deterioration, and over time, help to improve people’s health — helping them to live with dignity and independence.

Again, there are overlaps between this preventative agenda and the first two, insofar as an objective around preventing disability and ill-health helps us to focus on preventing the negative health impacts of poverty, and on enabling the positive health impacts of good work.

Seeing and doing things differently

What would be the implications of this agenda? On the one hand, this is about seeing the disability benefits system differently. PIP, for example, helps to prevent the damage that being disabled or unwell can do on claimants’ ability to participate in society, which in turn can prevent some of the health impacts of isolation and inadequate support. It’s important to see this as an important achievement in and of itself.

But it is also about doing things differently. There is a pressing need to better join up the benefits system and the health service. In a 2023 essay for Citizens Advice, Kayley Hignell advocated a much greater role for occupational therapists (OTs), on the basis that occupational therapy offers ‘adjustments to the way you live by looking at the relationship between the activities you do every day, the challenge you’re facing, and your environment’. OTs would be a larger feature of health services, as well as playing a role in supporting people into work, and assessing benefit eligibility.

Our subsequent report Disability Benefits: Lessons from the Front Line recommended a stronger link between benefit assessment processes and health services more generally. Assessments would become a way for people to access a wide array of support and advice. The goal of improving health, designed into the system for assessing ill-health. Of course, this would likely entail greater investment in the NHS as well as reform of the benefits system.

Some of the reported features of the forthcoming green paper can be viewed in this light. We can expect proposals such as (partially) replacing PIP payments with one-off grants (e.g. for medical equipment), and abolishing the WCA in favour of using PIP assessments as a singular gateway into disability and incapacity benefits, to resurface. We may see a greater emphasis put on medical evidence, in either/both the WCA and PIP assessments.

While reducing PIP rates should be ruled out, there may be scope for a single assessment process, increasing access to grants for equipment, and for involving medical expertise in assessments to a greater extent. Yet these should only be taken forward on the basis of wholesale reform of how assessments currently work, with appropriate NHS services involved in undertaking and verifying assessment as part of a wider care plan centred on prevention and embodying personalised support. PIP assessments are currently not fit for purpose, and extending their use into Universal Credit could exacerbate the kind of problems we see on a regular basis.

In this context, it would become conceivable that we might see a greater segmentation of PIP rates for future claimants (there are currently higher and lower rates for both the daily living and mobility components). And certainly, reform of Universal Credit health elements might be appropriate, to address the chasm between those qualifying for the additional LCWRA income and those people who, despite long-term health problems, rely on only standard Universal Credit rates[13].

Cost would not be the decisive factor in such reforms in any direct sense. Caseload reduction is a legitimate aim for policy-makers, but it should be achieved primarily by helping people into sustainable work where possible, and improving their health, not by cutting access to disability and incapacity benefits (or the highest rates of payments).

It is right that the government is considering the role of employers in this space too: disabled people, and people with long-term health conditions, can be helped to find and maintain work through employers encouraging flexible working and making reasonable adjustments to working conditions. But this should be in addition to — not in place of — support from the welfare state.

It is not wrong per se — and it is probably inevitable — that welfare policy-makers prioritise cost considerations. But we can control costs by suppressing the supply of disability and incapacity benefits, making the lives of many disabled people and people with long-term health problems even harder. Or we can do it the right way: by addressing demand, that is, the underlying health problems, and barriers to labour market engagement, that have created the need for rising benefit spending.

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*Names have been changed

This essay has been authored by Craig Berry, Maddy Rose, Victoria Anns and Simon Collerton. The authors are grateful to Luke Young, Anne Pardoe, Becca Stacey, and Eleanor Sutherland for comments and support on this essay, and to all of our colleagues in the Families, Welfare and Work team at Citizens Advice — past and present — for helping us to develop our analysis and ideas.

Notes:

1. It is also worth noting that, if someone provides informal care for someone in ill-health, they can also receive financial support through the benefits system (both universal and means-tested), recognising the impact on their own ability to work.

2. PIP replaced Disability Living Allowance (DLA) in 2013; DLA is still available for children.

3. The LCW group used to get an additional (lower) award until 2017, but for subsequent claimants this status only means they are exempt from searching for a job — but they may still be required to prepare for employment in the near future, with activities mandated by job centres.

4. Note that 46% of all the people Citizens Advice helped in the last year, and 64% of the people we helped with the benefits system, were disabled or had a long-term health problem. The processes for claiming PIP and the UC health elements are also major advice areas: we supported more than 275,000 people with issues around claims for and the administration of PIP and UC health elements in the last year.

5. Informal carers for disabled people, and people with long-term health problems, are having it hard too. Many need to take up paid jobs alongside caring responsibilities in order to make ends meet, but there are strict and complex rules on how much they can work, leading many to inadvertently accrue significant ‘overpayment’ debts.

6. The Labour Party’s 2024 manifesto promised to ‘reform or replace’ the WCA, and the Autumn Budget 2024 confirmed that savings equivalent to the previous government’s plans were expected from shorter-term WCA changes.

7. Furthermore, we know that spending on the state pension is by far the biggest growth area of welfare spending.

8. The only exception is for illnesses related to pregnancy, childbirth and the post-partum period, with a LCWRA outcome proportion of 50% (and note that the proportion for musculoskeletal system conditions is the same as for mental and behavioural disorders).

9. For example, ‘haggling’ is something that some people struggle with in these circumstances).

10. Furthermore, according to research by Money and Mental Health, there isn’t a significant difference in extra costs between people with ‘milder’ and more severe mental health conditions.

11. In a recent paper for the Health Foundation, the chair of the government’s Labour Market Advisory board, Paul Gregg, said ‘[w]ork intensification… makes it harder for people with work-limiting conditions to meet the demands of lower-paid roles’.

12. It is also worth noting problems around Statutory Sick Pay. When people already in work develop health problems, decent sick pay could mean they are able to retain their current job. But sick pay in the UK is low, and limited in scope, by international standards (although its extension to lower-paid workers by the new government will help). Insofar as people are compelled to exit work in order to claim incapacity benefits, reconnecting with the labour market at a later point invariably becomes more challenging.

13. Although we would contend that any reforms designed to produce more ‘accurate’ outcomes would have to weigh this aim against the downside of introducing greater complexity within the benefits system.