Is Britain is suffering from “sick note culture” or from unhelpful rhetoric and tired old policy?

The Prime Minister’s speech and press release on disability benefits last week was depressingly familiar. The formula of “moral mission”, “unsustainable cost”, “toughen-up testing” followed by a bit of “they are gaming the system” has been used repeatedly over the past decade – a decade in which the benefit system failed to prevent a huge rise in poverty, hunger, foodbank use and destitution. It seems unlikely that the same rhetoric, leading to more extreme versions of the same policies, will lead to different outcomes this time.

There has been much criticism of the speech around its “insulting” and “harmful” rhetoric towards those who need support and his use of the unhelpful phrase “sick-note culture”. To me the Prime Minister appeared utterly disconnected from reality when he expressed pride in the benefit system and used the word “generous” to describe “our safety net” when half of Universal Credit claimants regularly skip meals, 1 in 10 British families are food insecure and 3.8 million people experience destitution.

However, the premise of the speech has gone almost unnoticed behind the other controversies, and it is worth examining. The stated motivation for the speech was an assertion that post pandemic there are lots of people, especially young people, who are “economically inactive”, mostly because of mental illness – and that this is a substantive cause of our economic problems. That may be the story the Government wants to tell, but it is not a story the evidence supports.

Levels of economic inactivity are actually low

The UK has a lower rate of absence from work than any major economy bar South Korea, which makes the charge of “sick-note culture” seem odd. You may be surprised to know that economic inactivity levels in the UK are well below average for other major economies. You might also be surprised to learn that the levels of economic activity – usually defined as adults not working (or actively looking for work) – are at historic lows.

The graph below is of people aged 16-64 not in work for any reason – from sickness or disability to being in full time education, all the way through to early retirement. There has been larger than usual variations since the pandemic, but the UK remains well below the average for the past 10, 20 or 30 years. In context the current numbers are unusual – not because we have an epidemic of inactivity but for exactly the opposite reason – that they are historically and internationally low. While the country faces huge economic challenges, they are not to be found in high levels of inactivity.

Graph showing the number of 16-64 year olds not in paid employment from January 1980 to April 2021. It shows overall a decrease, with an increase to just below 35% in 1983, then down to about 27% in 1991, up to 32% in 1995 and then steadily down to 26% until 2006 with an increase to 30% in 2010 and then a steady decline to 20% until 2021

As for young people, the proportion of 16-24 year-olds not in work is indeed higher than before the pandemic, but if you look at the proportion not in work or education the number is 15%: exactly the same as before the pandemic. It would appear young people are not suffering from a ‘sick-note culture’ but a culture of education and self-improvement. Young adults educating themselves would seem an improbable cause of our economic problems.

Graph showing the proportion of young people in work or in education. It shows that from 2010 it was about 50% of young people not in paid employment, dropping to 45% in around 2015 and up again to 50% in 2020 then a decline and increase again in 2022. It shows a similar pattern of young people not in paid employment or full time education, but about 30% less.

Benefit claims

The speech and much of the commentary has conflated economic inactivity with benefits claims. Economically inactive people often do not qualify for or claim benefits (e.g. homemakers, students or those who have retired early). That means that the economic inactivity numbers are only very loosely related to the benefit claimant numbers.

The Government’s assertions about rising benefit claims are hard to disentangle because consistent statistics that enable comparison over time are not available. There are currently two generations of the benefits system co-existing. For the out of work, Employment Support Allowance (ESA) is gradually being replaced by Universal Credit. Personal Independence Payment (PIP) is designed compensate for the additional costs of having a disability regardless of employment status, meaning many claiming this are in work. PIP is in the process of partially replacing the earlier Disability Living Allowance (DLA). A change in the numbers for any of these benefits, separately or combined, may be due to moves between benefits, changes in eligibility criteria between benefits, or an increase in new claims.

A further complication is that as the pension age increases, the number of people encompassed by the term “working age” has changed over the past few years. 60- to 66-year-olds are now included in the figures and are much more likely to have a medical condition or disability than younger groups. It is possible to create consistent data so useful comparisons of the long-term trends can be done, but the Government has chosen[1] not to, (although some academics have done their best with the published information).

What story fits the data?

We can say with confidence that a historically and internationally high proportion of the population is in employment. The Government insists that employment improves both poverty and mental health – however we also know that on a population level that as employment rates went up, so too did poverty, destitution, hunger, and mental health issues – even before the pandemic accelerated the trends. It seems counter intuitive but for the past decade in the UK, higher employment, higher poverty and worse mental health all went hand in hand. That policy makers are not more interested in this is frankly astonishing.

We can also say with confidence that mental health issues are increasing, and that this is an important factor in why many people become economically inactive, especially over the long term. This has been the trend for 25 years which the data suggests the pandemic sped it up. The record NHS waiting lists, and the mental and physical health hangover from the pandemic are also likely to be significant factors. The increases in PIP applications referenced by the PM are neither surprising, nor in the context of a nation the size of the UK, particularly large.

Tougher tests and less money won’t improve mental health

Just as the rhetoric of the Prime Minister’s speech was depressingly familiar, so were the policy prescriptions. The unevidenced accusation that people are “gaming the system”, means that “to maintain public confidence”[2] health testing must be tightened up and made more difficult to pass. Such statements are frequent, and changes to the tests regular. Indeed the last major toughening up of PIP led a high court judge to rule that the assessment discriminated against people with mental health problems.

There were also the customary “tough” statements about how there would be new rules to remove benefits from people who do not comply. All the circumstances the Prime Minister mentioned would already lead to benefits being removed, so we await the regulations to see what this actually means in reality.

The Prime Minister announced he was “introducing a new personalised, tailored approach to employment support” which sounded great. It also sounded great when we were told that Universal Credit Work Coaches were going to provide personalised and tailored support from 2013. Many Work Coaches are wonderful and move mountains to help their clients, but the ratio of coaches to claimants was designed to be 1 to 373, meaning less than 4 hours of personalised support per year. In reality most claimants have only impersonal bureaucratic communications via the online journal, with Work Coach attention focussed on the people who have the most stringent conditions placed on them. Even then most of this interaction is setting conditions and policing them rather than anything that could be described as personalised support.

Personal support requires time for relationship building – which is expensive. Moreover, there is a growing body of evidence[3] that employment advice given alongside the threat of having benefits stopped means the advice is less effective – and in some cases worse than useless. Threatened claimants focus on complying and avoiding punishment and are less able to focus on looking for appropriate work.

Applying the logic of the benefit system to the whole British population

The only new idea in the Prime Minister’s speech was to say family doctors should no longer be responsible for determining if people are fit for work. This simply extends the logic of the benefit system to the entire working population. Since the mid-1990s successive rounds of benefit reforms have argued that benefit claimants’ doctors are too predisposed to say their patients are unfit to work and qualify for benefits. Therefore, decisions on benefits were over time completely taken out of the hands of claimants, GPs and medical specialists and given to DWP decision makers[4], who were “advised” by reports from private contractors such as ATOS.

This was a disaster. The appeals system quickly became so overwhelmed that a bureaucratic hurdle called a “Mandatory Reconsideration” had to be placed in the way of claimants appealing to an independent tribunal. The fine people of Glasgow nicknamed their assessment centre “Lourdes” – as people would go in sick but according to the assessors, come out miraculously healed.

The DWP predicted large falls in the number of people claiming sickness benefits because at that time there were also unevidenced claims that large number of people were “gaming the system”. While a huge number of people’s lives were upturned, and much stress and hardship was caused, the reduction in sickness benefits claimants never materialised.

Liverpool University used a longitudinal study to estimate that the mental health cost of this assessment process and found that it appallingly resulted in around 1 million antidepressant prescriptions and 600 suicides in its first three years of full operation.

Most of us view a relationship with a doctor as an advantage. We can listen to their advice trusting that as much as possible they have our best interests at heart. Removing that relationship from decision making about work and health had awful consequences for the most vulnerable in society. The proposal to remove it from decisions affecting yet more vulnerable people needs to be viewed with profound scepticism, especially as it is proposed as a solution to a problem that doesn’t appear to exist.

Putting relationships and trust at the heart of the benefit system

The “sick-note culture” argument appears to be little more than a reheated version of “scrounger verses striver” rhetoric of a decade ago. Like any tribute act it can stir memories and emotions, but it offers little creative or new.

One million children experience destitution each year, a number that has tripled over the past decade. We need new and creative thinking. The understanding of poverty that underpins these tired old policies is at best superficial and at worst plain wrong.

If we are not to repeat the tired old debates around poverty, we need to invite new voices to join the conversation. The Let’s End Poverty movement aims to put poverty at the heart of the next election campaign and includes leaders who live the realities of today’s poverty. Superficial and incorrect understandings of poverty do not survive contact with such experts by experience.

This approach can generate new and hopeful ideas. Just one example. The Trussell Trust and Joseph Rowntree Foundation, both members of the Let’s End Poverty movement, worked alongside people with experience of poverty as they co-created the Essentials Guarantee – the simple ask that benefit levels should be set to enable families to meet their essential needs.

Let’s End Poverty is currently encouraging local communities in areas of deprivation to hold conversations about their hopes, dreams and challenges, and what they feel needs to change. The new Neighbourhood Voices toolkit will help you to do that, so that the experiences of those in poverty are heard more widely in this election year, and we can challenge all aspiring politicians to truly listen.

Securing a commitment from political leaders to engage with and tackle the real causes of poverty – in partnership with experts by experience – would be a truly healthy change in culture.

[1] The Alternate Claimant Count was an attempt at this but stopped being published in 2022.

[2] I particularly dislike the increasingly common “to maintain public confidence” formulation. I view it as cowardly, as rather than have the courage to say “we the government believe there are cheats” (and subject itself to the obvious questions of “where is your evidence?” and “why do you believe your last round of “tightening up” failed?”) it implies it is not them, but the public, that seeks harsher treatment for the least well off. Speeches like this also have the effect of reducing public confidence.

[3] There is a growing consensus on this see for example: House of Commons Library: Department for Work and Pensions policy on benefit sanctions debate pack, Benefits and tax credits, The IFS Deaton Review of Inequalities,  Codreanu, Mihai and Tom Waters (2023) Do work search requirements work? Evidence from a UK reform targeting single parents or (sadly paywalled) Card, D, J Kluve and A Weber (2010), “Active labour market policy evaluations: A meta‐analysis”, Economic Journal 120(548): F452–F477.

[4] Decision Makers are technically are making decisions on behalf of the Secretary of State often using the Royal Prerogative, which makes legal challenge exceptionally complicated and expensive. This also ensures that the normal appeals do not set a precedent, creating huge uncertainties as the same circumstances can legally lead to different outcomes.


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