Monday, 9 April 2012

The Work Capability Assessment: a case of history repeating itself

Thousands of people’s lives are being turned upside down by the new assessment regime – the Work Capability Assessment (WCA) – used to determine eligibility for out of work sickness benefits (Employment and Support Allowance).

The WCA is based on the biopsychosocial (BPS) model.  This was originally developed as a way of taking a more holistic approach to people’s experience of ill health and impairment.  In its most straightforward application it is a way of acknowledging that the experience of illness and/or impairment will be influenced by not only by the biology of the condition (the ‘disease’ or ‘impairment’) but also by the social and economic context, and by individual psychology.

As an approach, the BPS model can be, and has been, presented as ‘progressive’ and as a corrective to the over-medicalisation of people’s experiences of their bodies. Feminists and others have long challenged the authority of the medical profession as the sole source of knowledge and treatment.  Such challenges emphasise more holistic explanations of people’s experiences of their bodies and their mental health, arguing against biology as sole cause and medicine as sole treatment. The BPS model also purports to acknowledge the value of the social model of disability, developed by the disability movement from the 1970s onwards.

However, while there are theoretical and evidence-based arguments to be had about the relative influence of, and the interaction between, biological, psychological and social factors, the current problem with the BPS model is the way it has been applied in the context of governments’ attempts to reduce the amount of money spent on out of work sickness benefits.  

Jonathan Rutherford has described the influence of the insurance industry on the way the BPS model was applied when the Labour Government replaced Incapacity Benefit with Employment and Support Allowance ('New Labour, the Market State and the End of Welfare', Soundings, 2007, Issue 36). The government was concerned that ‘too many’ people were qualifying for and remaining on Incapacity Benefit, while the insurance industry was motivated to limit successful claims on Income Protection Insurance.  

In this context, as Gill Thorburn explains in her excellent analysis, the BPS has been applied with “a relentless emphasis on an individual’s ‘beliefs’and ‘attitudes’ towards their illness…. In this sense it could more aptly be termed the ‘Psycho’ model of illness”. 

It is clear, not just from the political debates and media coverage, but also from the testimony of those subjected to the WCA, that a number of assumptions are made when determining eligibility for ESA:
- that some people’s experiences are ‘subjective’ because their self-reported restrictions are supposedly not ‘explained’ by what is clinically measured
- that these accounts of restrictions are therefore not trustworthy
- and that someone acting on behalf of the state must make a judgement about the level of restrictions actually experienced.

So, an approach which attempts to acknowledge the whole of a person’s experience, rather than just that which can be measured by a medical professional, has been turned into a way of justifying what are essentially moral judgements about whether a person is ‘really sick or disabled’.   

Moreover, these moral judgements are being outsourced by the state to a private company, Atos [Update 2015: Atos walked away from the contract and it was then given to Maximus].  Since the purpose of introducing the WCA is to reduce the numbers eligible, Atos’ ability to renew this and gain other similar contracts (such as that for the forthcoming Personal Independence Payment) is likely to be linked to how many (or rather, how few) people are judged ‘fit to work’. After all, one of the key reasons for replacing the old Personal Capability Assessment was that it was resulting in ‘too many’ people qualifying for out of work sickness benefits.

The conflict over so-called ‘subjective’ experiences of illness and impairment is being played out in the appeals made by 40% of those deemed ineligible for ESA.  The cost of appeals in 2010/11 was £48.2million and 145 additional judges are being recruited to deal with the mounting backlog of cases.

The motivations, and assumptions, behind the WCA and its operation are not new, however.  Those administering the Poor Law in the seventeenth century were concerned to weed out ‘sturdy vagabonds’ from making claims on public resources, and distinctions have been made between the ‘deserving’ and ‘undeserving’ ever since. David Turner, in his paper ‘Fraudulent disability in historical perspective’ points out how:

The development of the news media during the eighteenth century led to increased stereotyping of the disabled, with attempts to sort ‘genuine’ from ‘faked’ conditions and differentiate between good and bad disabled types.  This led to calls for welfare relief to be based on firmer medical principles, together with proposals to return the sick and disabled to the workforce. 

Sounds familiar doesn’t it?

The history of collectively funded provision for those who cannot sell their labour because of impairment and/or illness, is marked by countless points at which the state, supported by popular media, decides that the current rules and procedures to determine eligibility are too slack, and instead introduces new systems which it is thought will better identify the ‘genuinely sick and disabled’ and thereby reduce the numbers qualifying for support.

Each new system is supposedly based on a more ‘objective’, ‘scientific’ way of determining eligibility.  All that has changed over the years is that the academic underpinnings of the WCA are assumed to be more valid than the methods used by the Poor Law Guardians to determine who was ‘really sick’.  But if the history of medicine shows anything it is that there is often a gap between what it can explain and measure at a particular moment in time, and what people’s actual experiences are. We shouldn’t forget that it isn’t so long ago that the symptoms of autistic spectrum disorders were diagnosed as children’s psychological reactions to dysfunctional parenting (‘fridge mothers’ as the popular term went).  And to take a more recent example highlighted by Gill Thorburn, medical technological developments are highlighting the limitations of conventional MRIs in the diagnosis of musculoskeletal problems, one of the key conditions held up as ‘medically unexplained’ when such scans fail to show any ‘objective’ evidence of a patient’s ‘subjective’ experience of pain,

Individuals and organisations are mounting convincing criticisms of the validity of the WCA and the assumptions underpinning it. What is also important, however, is to address the two underlying factors running through the whole history of out of work sickness benefits, namely:

-   political and economic factors which create a desire to limit or reduce public expenditure on supporting those who cannot support themselves through selling their labour
-   the unequal relationship between those who design and deliver the welfare system and those who are subjected to it.

If we want to defend and promote a welfare system which does not punish people for being unable to sell their labour, we have to develop an economic system which can sustain a level of taxation sufficient to fund support at a level which affords a decent standard of living for all.   

If we want to defend and promote a welfare system which treats people with respect, and which seeks to empower them as citizens, then we have to develop a welfare system which is co-produced by those who depend on it. 

This may sound utopian but, unless we address these fundamental political and economic issues we will only keep repeating the battles we fought yesterday and the future for disabled and ill people will be very bleak indeed. 

Note: On the day I published this Disabled People Against the Cuts also published this really interesting piece by Debbie Jolly about the social model and the BPS