Abstract
As the world is preoccupied by the pandemic, and the British public are beginning to comprehend the full impact of Brexit, the predictable public mental health crisis created by the demolition of the UK social safety net has been disregarded by successive administrations. Few people realised that preventable harm was the inevitable creation of social policy reforms, gradually adopted by every administration since Thatcher, en route to her political ambition which was the demolition of the welfare state to be replaced by private health insurance. In order to demolish the welfare state, it was first necessary to remove the past psychological security provided by the welfare state. This has been achieved, with disability denial created by significant social policy reforms since 2008. To justify the adoption of harsh and unnecessary austerity measures, which were introduced without ethical approval, the Coalition administration elected in 2010 vehemently challenged the integrity of the chronically ill and disabled community and routinely accused disability benefit claimants of fraud; while failing to produce evidence to support their claims. Their often hostile rhetoric encouraged a 213 percent increase in prosecuted disability hate crimes, and successive administrations disregarded the thousands of deaths directly linked to the Work Capability Assessment, which was adopted using a discredited and dangerous biopsychosocial model of assessment to restrict access to long-term disability benefit. Influenced by corporate America since 1992, the UK social policy reforms guaranteed that many of those in greatest need were destined to die when, covertly, killed by the State.
Introduction
Margaret Thatcher (1925–2013) is revered by the Conservative Party as a historical political leader and Prime Minister (1979–90). Attended by members of the Royal Family, her funeral in 2013 attracted world leaders and there is a large statue of her at the entrance to the Members’ Lobby in the Palace of Westminster, directly opposite a statue of Winston Churchill. However, Thatcher’s devotion to neoliberal politics, which is the ideology that supports free market competition with an emphasis on minimal State intervention, would eventually be identified as being at ‘the root of all our problems’ (Monbiot, 2016). Thatcher’s well-documented informal transatlantic alliance with the US President Ronald Reagan from 1981–89 (Scott-Samuel et al, 2014), and her insistence that the welfare state was an unacceptable financial burden on the public purse, opened the door to the influence of corporate America with UK social policy reforms and the ‘planned demolition of the UK welfare state’ (Stewart, 2016).
Every 30 years confidential Cabinet Papers from past UK governments are released into the public domain. In 2012, the 1982 Cabinet Papers from the first Thatcher administration (1979–83) were released, offering evidence demonstrating the political expectation to eventually demolish the UK welfare state, including the National Health Service (NHS): ‘… there could be a danger of under-insurance by the working population, and thought might therefore have to be given to a scheme for compulsory private insurance’ (Cabinet, 1982). Papers written 40 years ago identified ‘an increasing correlation between the government’s economic and social policies’ (Demissie, 2012), which continued.
Thatcher’s social policy right-leaning neoliberal legacy was continued by every successive administration. This included introducing American corporate influence for the development of UK social policy reforms by the Major administration (1990–97) (Stewart, 2018); the adoption of American social and labour market policies by the Blair administration (1997–2007) (Daguerre, 2004; Daguerre and Taylor-Gooby, 2004); the adoption of the Work Capability Assessment in 2008 to limit access to the new Employment and Support Allowance (ESA) disability benefit by the Brown administration (2007–10) (Gentleman, 2011); and the increased use of sanctions, which removed all income to successfully intimidate disability benefit claimants, and to starve some of them to death (Pring, 2020a), by the Cameron-Clegg Coalition administration (2010–15).
The influence of corporate America with UK social policy reforms was introduced in 1992, when the John Major Conservative administration invited UnumProvident Insurance to consult regarding how to limit access to welfare funding (Stewart, 2016; 2018). By 1994, the UnumProvident Vice-President John LoCascio was appointed as the UK official government adviser for future welfare claims management. Shortly afterwards, the 1994 Social Security (Incapacity for Work) Act introduced the new Incapacity Benefit (IB), which created ‘the most radical piece of social security legislation since the Social Security Act 1986’ (Wikeley, 1995).
Initially adopted by UnumProvident Insurance in America to limit funding genuine health insurance claims (Langbein, 2007), and aided by the government’s chief medical adviser Mansel Aylward, John LoCascio advised the Major administration how to create the non-medical biopsychosocial (BPS) functional assessment in the UK; as adopted by the Department for Work and Pensions (DWP) to remove the opinion of General Practitioners (GP) for claimants of long-term disability benefit. Their research paper (Aylward and LoCascio, 1995) supported testimony from the American health insurance industry, and argued that family doctors should not be expected to determine a patient’s incapacity. Hence, the past authority and clinical opinion of GPs in support of their patients claiming long-term disability benefit would be curtailed by future social policy legislation, co-designed by corporate America (Stewart, 2016; 2018).
The creation of preventable harm
By definition, ‘preventable harm’ is identified as meaning ‘the presence of an identifiable, modifiable cause of harm’ (Nabhan et al, 2012). The abandonment of the clinical opinion of GPs was achieved when Incapacity Benefit (IB) replaced Invalidity Benefit as the long-term out-of-work disability benefit (Wikeley, 1995). The ‘All Work Test’ was introduced in 1995 for the assessment of IB claimants to restrict access to the new disability benefit, which was identified as highlighting the division between the ‘deserving’ and the ‘undeserving’ poor (Wikeley, 1995). This ‘All Work Test’ adopted the Aylward and LoCascio (1995) BPS ‘non-medical functional assessment’ (Stewart, 2018; 2019), which followed the design of the BPS assessment model adopted by UnumProvident Insurance in America (Langbein, 2007; Rutherford, 2007).
While the adoption of the ‘All Work Test’ restricted disability benefit claimants, there was a growing number who had a mental health problem and, by 2005, a total of 39 percent of IB claimants had a mental health problem; which was just under one million people (Rutherford, 2007). Since that time, every administration since Blair’s has insisted that there is a need to reduce disability benefit claimant numbers by one million (Groves, 2015); suggesting that mental health problems are not considered a priority for financial support by the State. In order to further reduce disability benefit claimant numbers a more stringent assessment model was needed.
At UnumProvident we have a non-medical, enabling model of rehabilitation and we are working with our partners at the UnumProvident Centre for Psychosocial and Disability Research at Cardiff University to better understand what makes people at risk of long-term or chronic illness. (Evidence provided for the Work and Pensions Select Committee, 2006). (Stewart, 2019)
Continuing with Margaret Thatcher’s social policy legacy, the ambition of the Blair Labour administration was to make access to disability benefit as difficult as possible by adopting American neoliberal social and labour market policies (Daguerre, 2004); which was achieved as all the Waddell and Aylward (2005) recommendations were eventually adopted by future social policy reforms. What is not commonly known is that, historically, UnumProvident Insurance have a disturbing reputation in the US for failing to fund or to intentionally delay payment of genuine health insurance claims (Langbein, 2007) and, in 2008, the American Association for Justice identified the company as being the second worst insurance company in the US (AAJ, 2008). This is the same American corporate giant that influenced UK social policy reforms since 1992 (Aylward and LoCascio, 1995; Waddell and Aylward, 2005; 2010; Stewart, 2020).
Here we explore the elisions and exaggerations that we believe render the Waddell-Aylward BPS approach conceptually and empirically invalid… We outline the chief features of the Waddell-Aylward BPS and argue that… there is no coherent theory or evidence behind this model. We have carefully reviewed claims in Waddell and Aylward’s publications; compared these with accepted scientific literature; and checked their original sources, revealing a cavalier approach to scientific evidence… The WCA was designed to provide a functional assessment, based on the premise that eligibility for ESA should not be determined by the description of a person’s disability or health condition but rather by how their ability to function is affected… They have also been used to drive changes in media representation of disabled people, promoting the myth that large numbers of claimants are fraudulent… Society must accept that work is not always appropriate or possible, and that for many disabled people humane and supportive alternatives are needed. These must not stigmatise those who are so supported, nor should non-working disabled people have to suffer poverty and social exclusion. In conclusion, the relationship of the advocates of the Waddell-Aylward BPS to the UK government’s ‘welfare reform’ does not represent evidence-based policy. Rather, it offers a chilling example of policy-based evidence. (Shakespeare et al, 2016)
Hence, the introduction of the WCA in 2008 by the Labour administration, using the flawed Waddell-Aylward BPS model of assessment (Ravetz, 2006; Shakespeare et al, 2016), guaranteed that chronically ill and disabled ESA benefit claimants were destined to suffer given that the WCA is the adoption of the discredited Waddell-Aylward (2005; 2010) BPS ‘non-medical functional assessment’ (Stewart, 2016; 2018; 2019); as all clinical opinion is disregarded by the WCA, and disregarding diagnosis and prognosis was guaranteed to create death, despair and preventable harm for many of those in greatest need (Stewart, 2020). Thousands of chronically ill and disabled ESA benefit claimants were destined to die, with their deaths linked to the WCA process after having been declared ‘fit for work’ by the flawed assessment (Butler, 2015; BBC News, 2015; DWP, 2015), which meant that, on average, ‘nearly 90 people per month were dying after being declared fit for work’ following a WCA (Butler, 2015). Consequently, the DWP refused to publish future death totals of claimants found ‘fit for work’ following a WCA, so the total number of deaths since February 2014 is unknown.
DWP mortality statistics, ESA claimants: December 2011–February 2014, published August 2015
| WCA outcome at most recent ESA assessment December 2011–February 2014 | Number of claimants leaving ESA with a recorded date of death |
|---|---|
| Fit for work | 2,380 |
| Work-related activity group | 7,200 |
| Assessment phase | 7,540 |
| Support group | 32,530 |
| Unknown | 930 |
| TOTAL | 50,580 |
Source: Reproduced from DWP evidence, published in August 2015. Table created by author.
The Coalition increased public anxiety by insisting that all IB claimants, including those with a lifetime award due to a permanent profound illness, were to be reassessed. Suicide attempts of ESA claimants spiralled, with a previously unpublished 2014 NHS report identifying that almost 50 percent of ESA benefit claimants had attempted suicide at some point (Pring, 2017). Subsequently, Coroners’ warning letters identifying the flaws in the DWP assessment process linked to deaths of claimants, often by suicide, were disregarded by the DWP (Pring, 2020b; 2015a). The DWP also failed to alert the occupational medicine consultants, initially appointed to review the WCA, of the increasing numbers of deaths linked to the assessment (Pring, 2019); and they have been ‘very lacklustre’ in their adoption of the recommendations identified to improve the claimant experience of the WCA (WPSC, 2021). This was the creation of ‘State crime by proxy’ (Stewart, 2018).
The adoption of the politics of fear
The Coalition government were elected in May 2010 with claims of the need to reduce the budget deficit and, by June 2010, the multi-millionaire Chancellor George Osborne MP announced the intention to introduce austerity measures, which would reduce the claimed excessive welfare spending by the previous Labour administration. This claim, that the Labour administration had spent excessively on social security funding worked well, was adopted by the right-leaning national press to encourage the public to accept the need for austerity measures, and justified what was to become a catastrophic political attack on the welfare state; with those in greatest need about to suffer more than any other group (Duffy, 2014). Eventually, the Institute for Fiscal Studies (Banks et al, 2015) identified that the expenditure on welfare was at its peak in the UK in 1995–96, during the Major Conservative administration. So, the justification for the adoption of austerity measures was unfounded and was used to successfully mislead the British public, and the UK parliament, to accept the adoption of severe austerity measures. This was the continuation of the political ambition to remove the past psychological security of the welfare state to make it easier to eventually remove, and replace with private health insurance; which is the long-held political ambition that enjoys bipartisan support (Stewart, 2016).
Few people realised that the formation of a UK Coalition government following the 2010 general election would introduce social policy reforms which were destined to create a public health crisis (Garthwaite, 2011; 2014; McKee et al, 2012; Patrick, 2012; Doherty and Gaughran, 2014; Hale, 2014; Barr et al, 2016; Mehta et al, 2018; Cummins, 2018; Dwyer, 2018; Dwyer et al, 2019; Boardman, 2020). The joining of the historically lenient Liberal Democrats with the often severe Conservatives, to form the Coalition, gave rise to hope that social policy extremes would be restricted. However, the Coalition adopted the ‘politics of fear’ (Stewart, 2020) to successfully remove the past psychological security provided by the welfare state.
A pattern of violence seems to be a common thread in disability hate crimes. 44 percent of hate crimes towards disabled people in England and Wales were categorised as violent (i.e. involving assault or possession of weapons), an increase in 4.4 percent compared with the previous 12 months. Despite this alarming statistic, hate crime against disabled people does not seem to be treated as seriously as for other forms of hate crime. (Reilly, 2021)
Duncan Smith successfully claimed that fraud was a significant problem for the growing welfare budget (Garthwaite, 2011), which negatively impacted on what had been the past public support for the disabled community. In reality, when Duncan Smith was creating a moral panic by claiming that there were excesses of fraud by benefit claimants, the DWP’s published figures were stating the opposite. In fact, the ‘fraud rate for sickness benefits is just 0.5 percent, meaning that 99.5 percent of claimants are not fraudulent’ (Garthwaite, 2014). His hostile claims about benefit claimants informed public opinion to the detriment of the chronically ill and disabled community (Garthwaite, 2011; Brient et al, 2013; Barr et al, 2016), as reproduced by tabloid press banner headlines.
Daily Express banner headlines, January–April 2011
Citation: Justice, Power and Resistance 2023; 10.1332/GQDH4178
Source: Courtesy of Mirrorpix.Daily Express banner headlines, January–April 2011
Citation: Justice, Power and Resistance 2023; 10.1332/GQDH4178
Source: Courtesy of Mirrorpix.Daily Express banner headlines, January–April 2011
Citation: Justice, Power and Resistance 2023; 10.1332/GQDH4178
Source: Courtesy of Mirrorpix.Whilst government policy has increasingly distinguished between ‘deserving’ and ‘undeserving’ in relation to sick and disabled people, it is not only policy that makes that distinction. In recent years, the media have taken a more vitriolic stance towards sick and disabled people, often branding them in deeply offensive terms such as ‘scum’, ‘feckless’, and ‘work-shy’…. (Garthwaite, 2011)
The majority of narratives revealed a huge amount of fear and trepidation over ongoing welfare reform. Participants spoke about worrying about the assessment on a daily basis, accompanied by a deep mistrust of the entire system… Some respondents specifically mentioned their fear over receiving an official-looking brown envelope through the letterbox – a possible indicator of a communication from the DWP… Such a language of scroungers and benefit cheats is creating a realm of fear for sickness benefit recipients, and neither is it conducive to encouraging potential employers to employ someone who has a history of sickness benefit receipt. (Garthwaite, 2014)
The worst thing, I find, is realising that I am forced into looking for a life that I want but have no chance of having. I seriously feel I may kill myself because being sick, having next to no money, no life, no future, no cure, constant pain and disapproval and rejection defeats me. (Hale, 2014)
The programme of reassessing people on disability benefits using the Work Capability Assessment was independently associated with an increase in suicides, self-reported mental health problems and anti-depressant prescribing… Our 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 professionals have professional and statutory duties to protect and promote the health of patients and the public, our evidence that this process is potentially harming the recipients of these assessments raises major ethical issues for those involved… Our study provides evidence of the policy in England of reassessing the eligibility of benefit recipients using the WCA may have unintended but serious consequences for population mental health, and there is a danger that these adverse affects outweigh any benefits that may or may not arise from moving people off disability benefit. (Barr et al, 2016)
Conclusion
Despite an Early Day Motion (EDM) in 2019 by opposition MPs inviting an inquiry into deaths linked to the WCA (EDM, 2019), no progress has been made, and the DWP still refuse to publish the numbers of deaths of disability benefit claimants after being found ‘fit for work’ following a WCA, which should be in the public domain. As long as UK social policies are decided using a fiscal priority, while disregarding health and wellbeing, the chronically ill and disabled community will continue to live in fear of the DWP who find as many disability benefit claimants as possible ‘fit for work’, regardless of health, and ‘institutional violence’ (Redman and Fletcher, 2021) has been successfully adopted when aided by ‘dehumanised’ JobCentre staff, who were driven to sanction as many benefit claimants as possible. Other than neoliberal ideology, there is no justification for the continued use of the fatally flawed WCA, which was adopted by the UK administration demonstrating a total and catastrophic indifference to human need when influenced by corporate America. Many more chronically ill and disabled benefit claimants are destined to be killed by the State when driven to suicide by DWP persecution, or starved to death following a sanction, and many more will be killed by the State until someone is held to account for this identified ongoing UK government induced public health crisis.
Acknowledgements
I am very grateful to Frances Leckie and Graham Vanbergen for their helpful comments on an earlier draft of this paper.
Conflict of interest
The author declares that there is no conflict of interest.
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