Mental Health: Assessment

Angela Crawley Excerpts

Tuesday 22nd January 2019 Westminster Hall

[Angela Crawley (Lanark and Hamilton East) (SNP)]

I beg to move,

That this House has considered mental health and the benefits assessment process.

It is a pleasure to serve under your chairship, Ms Ryan. I thank the hundreds of people who wrote to me via the call for evidence on the House of Commons Facebook page, as well as the digital support team at Parliament.

Many of the stories shared by people from across the country were harrowing and difficult to read, simply because of how badly they felt they had been treated. I cannot do justice to the subject without reading out some of the words that they used. The main themes that came out of the online contributions were that the process seemed to be making mental health issues worse; that people did not think that the assessors were qualified; that the amount of money awarded was simply not enough to live on; that the process was inappropriate and poorly conceived; and that people were often declared ineligible despite having mental health diagnoses, as well as support and evidence from their doctor.

One woman specifically said that she thought the process was “confrontational, intimidating and unsupportive”, and that

“frankly it is outright cruelty and very distressing.”

Another said that it was “degrading, embarrassing and exhausting”. She said:

“My assessment left me in tears and feeling suicidal because I’d spent all week getting ready, and not a single questions was asked about my mental health.”

Another person said that they did not have enough to live on and were

“trying to have one meal every two days.”

They could not afford a new suit to go to a job interview and the money that they were receiving was only enough to pay the rent, the electricity and their phone bill.

Another person said that as someone who had suffered from suicidal ideation, they did not know why the assessors thought that asking them about that would somehow transform or change the experience. They said it was “barbaric, pointless and unnecessary.” Many people said that charities helped them the most, not the jobcentre or even the NHS. It was local charities, which in many cases were funded by the EU, that were able to give them the support they needed. That is just some of the feedback from the online contributions.

[Gloria De Piero (Ashfield) (Lab)]

A young man from Ashfield—it is relevant that he is young—had severe anxiety and his doctor wrote to support his case. On the day that he was supposed to have his face-to-face interview at his house, the assessor did not turn up. The young man was so anxious about it that he suffered a heart attack. Is this not a disgraceful and sick way of treating people who are in need?

[Angela Crawley]

Absolutely, and I am sorry to hear about that constituent’s experience. It is harrowing. The assessment process has a detrimental impact on the lives of people who are already vulnerable and already not in control of their circumstances in many regards. For them to be put through a harrowing process and feel that way is simply unacceptable.

[Andrea Jenkyns (Morley and Outwood) (Con)]

Does the hon. Lady agree that the number of forms that people suffering with mental health conditions have to complete is a real problem? It can cause unnecessary stress during difficult times, especially when many of the forms are duplicated.

[Angela Crawley]

I could not agree more. During last week’s debate on fibromyalgia, she explained how the process and the application forms simply do not pay respect to mental health conditions. I champion her calls to the Government to change that process.

I urge the Minister to look through the comments, to get an idea of how the policies really impact people and to understand what they have gone through. Standing here and reading out the comments does them no justice; it is only by reading them that she will get an understanding of their point of view.

[Laura Pidcock (North West Durham) (Lab)]

The hon. Lady’s stories are a perfect depiction of the fact that the process is not adequately designed to assess mental health and wellbeing. Instead, it is a functionality test that lacks understanding of the nuances and fluctuation of mental health. If anything, the process actually exacerbates mental illness, meaning that people drop out of the cruel system to avoid and end acute worry. Let us hope that the Minister will not try to individualise the problems by saying, “Come and see us about these cases,” and that she will acknowledge the systemic failure of the assessment process.

[Angela Crawley]

I completely agree. I know that the Minister is always receptive and keen to understand and learn more. I am not going to harp on and give her a hard time about this. I am simply trying to change a process that I think we all want to see improved.

[Paul Blomfield (Sheffield Central) (Lab)]

Will the hon. Lady give way?

[Mr Jim Cunningham (Coventry South) (Lab)]

Will the hon. Lady give way?

[Angela Crawley]

I would like to make some progress first.

I am grateful to everyone who contacted me and took the time to comment, both on Facebook and through email, especially those who were brave enough to come forward and share their story. It is vital, given the needs of people with mental health issues, that the Government take time to listen to them.

Over the past few years there have been a great many public understanding and national awareness campaigns on mental health. Where mental health was once kept a secret from family, friends and colleagues, more and more people feel able to come forward and openly discuss their experiences of mental illness and get the necessary help. That recognition is largely due to the tireless work of national campaigns such as the Scottish Association for Mental Health, Mind and many others.

On 10 October last year, the Prime Minister held a reception to celebrate World Mental Health Day and to make a policy announcement, which included the creation of a Minister for suicide prevention. The Prime Minister said,

“we are not looking after our health if we are not looking after our mental health...we need that true parity between physical and mental health, not just in our health systems but elsewhere as well—in our classrooms, our workplaces, in our communities too.”

I agree with all of those points, but I would add that one of the biggest and most positive changes would be parity of esteem between mental and physical health in Government Departments themselves. That would be the place to start.

The highest number of people who seek my support are those who have been denied access or assistance by the Department for Work and Pensions. A common theme of the complaints I hear is that the constituent’s mental health needs have been ignored during work capability assessments for universal credit, employment support allowance and the personal independence payment. Most of those people have a genuine claim and have been incorrectly assessed. That is because the majority of decisions brought to me are ultimately overturned at the mandatory reconsideration and appeals stage.

[Mr Jim Cunningham]

I congratulate the hon. Lady on securing this important debate. On Friday night I met a number of people with mental health problems. Their issue is that the doctor says that they are not fit to work, but the benefits assessor says that they are, which leaves them in limbo. It is also a problem that employers do not always recognise mental illness. Does the hon. Lady agree that the Minister should do something about that?

[Angela Crawley]

I thank the hon. Gentleman for his intervention and I am sorry that I did not take it earlier. Each and every day, our constituency offices deal with situations where there has been an issue with the Department for Work and Pensions. It is our staff who work day in, day out to get those decisions overturned. If we have to do that, and if decisions are being repeatedly overturned, there is obviously a flaw in the system.

[Several hon. Members rose—]

[Angela Crawley]

I will let the hon. Member for Sheffield Central (Paul Blomfield), who tried to intervene earlier, speak first.

[Paul Blomfield]

I thank the hon. Lady for giving way. Clearly, there is competition for interventions because this is such an important issue. On the question of process, a constituent of mine scored zero on an employment and support allowance assessment despite having numerous and well-documented physical and mental health problems. The decision was overturned on appeal. The appeal was a gruelling process to go through but the decision was readily overturned, because there was a basic factual error in the first stage. Does the hon. Lady agree that the process would be much more effective if claimants had the option of their assessments being recorded, as recommended by Paul Gray, the independent reviewer? Does she share my hope that the Minister will update us on the pilot announced last June and confirm that her Department will go ahead with the recording of interviews?

--- Later in debate ---

[Angela Crawley]

I agree that there are issues with the service and the process.

[Ged Killen (Rutherglen and Hamilton West) (Lab/Co-op)]

I congratulate the hon. Lady on securing this debate. She will have seen, as I have, the number of people who visit constituency surgeries after having had an initial assessment for a physical health problem but then ending up with a mental health issue as a result of how they were treated and having their support incorrectly withdrawn. Does she agree that that needs to be looked at very seriously?

[Angela Crawley]

I wholeheartedly agree, and that is the point of this debate. If the system worked well and we did not have any complaints about it, we would not be here today, but the fact is that the system is not working as it should, nor as it was probably intended to work in its initial design or concept. It is simply not working in practice. If we were to amend that system and make it work better, we would probably spend less time going through administrative appeals and mandatory reconsiderations, which should incentivise the Government to get it right the first time.

Returning to my earlier point, it is my staff who deal with constituents’ cases every day, and I would like to say thank you to each and every one of them. Rhona, Josh, David, John, Mary-Jane, Carmen and, of course, Georgia—I have quite a few staff and think I have covered them all—work hard every day to have those cases overturned, because they can see the constituent before them and can see that person who is crying out for help and needs support.

Perhaps the assessors are just not getting that full picture of someone, and perhaps we are being unfair to all the staff who work at DWP, but there is a flaw in the process, which I will turn to now. The assessments are carried out by contractors of Maximus and Atos according to guidelines set by the Department for Work and Pensions. I know there have been changes and adaptations, but ultimately they are still not working. Turning to the administrative process administered by DWP, those assessment reports are then filtered into descriptors set by the policies of this Government. I do not believe that the assessors are given the correct level of training or resources to deal with mental health issues. I have written to the Department about that on a number of occasions and I have been assured that assessors are getting adequate training, but if that is not the experience on the ground, there is obviously a flaw or an issue there.

I do not believe that the criteria for assessments give enough credence to the crippling effects that mental ill health can have on people’s lives. As the hon. Member for Rutherglen and Hamilton West (Ged Killen) has outlined, that turns into a detrimental effect on people’s mental health, even if it did not start out that way. Indeed, many of my constituents complained that their mental health problems do not fit neatly into the assessment forms because the form is not designed to assess disability resulting from mental ill health, a point that the hon. Member for Morley and Outwood (Andrea Jenkyns) also covered.

One of my constituents from Hamilton, whose daughter has bipolar disorder and was denied personal independence payments, said,

“we see mental health brought up everywhere—in adverts, in TV soaps—and the advice is to speak out. But if you tell the DWP, they ignore you and do nothing to help, they have fallen behind the times and are not keeping up to the standard.”

In the assessment reports, indicators of mental ill health bear little relation to the advice of mental health charities and are at best unhelpful for diagnosis. The assessors will make wide-reaching assertions based on outdated ideas of mental health and often irrelevant judgments on the person’s appearance: “Was the person rocking in a chair? Were they trembling? Were they sweating? What was the person wearing? Had they washed or were they wearing make-up?” That is institutional stereotyping of people suffering from poor mental health. The fact that someone turned out that day and made the effort, even if it perhaps took them hours and days to prepare themselves for that experience, only to then have it marked against them, seems arbitrary and frankly ridiculous.

[Dr Dan Poulter (Central Suffolk and North Ipswich) (Con)]

I am sympathetic to a number of the points the hon. Lady makes, although, for an experienced medical professional, one component of assessing somebody who is unwell is looking at how they appear, because that may be a symptom of distress, self-neglect or other issues, notwithstanding the points she has made. One of the challenges she raised is that of those patients with fluctuating conditions such as bipolar disorder, who can be well for periods and then become quite unwell. Does she agree that the system does not have adequate assessments in place to allow for patients who can become very rapidly unwell, and that those patients in particular can become distressed by the system and how it is put into practice by assessors?

[Angela Crawley]

I agree with the second part of the hon. Gentleman’s intervention, but I return to my original point, which is that we are talking about a tick-box exercise that does not recognise the fluctuating nature of mental ill health—I think that is the point he is trying to make. Why should someone have the fact that they put make-up on that day, or made the effort to turn up and be there for the assessment, marked against them? It seems completely arbitrary and unnecessary.

The constituent I mentioned earlier has a nervous compulsion and, as a result, she picks at her nails. She has chosen to wear acrylic nails so that she will not unconsciously pick at her hands due to her nervous disposition. That was taken by the healthcare professional as an indicator that she was well kept and therefore mentally stable. It did not seem to matter that it was a form of self-harming and that she had had suicidal thoughts, which she outlined to the person. Those are Victorian and antiquated measures through which to identify someone with mental ill health, and they come up time and again. My constituent Donna from Carluke recently had a personal independence assessment. She acknowledged that she had two options: she could present as someone who had a mental illness and

“Present as they expect someone who has a mental illness to i.e and I quote here from your own assessment documentation ‘rock, shake, sweat, unkempt, poor eye contact and look unwell and troubled’”,

or she could present as she was on the day,

“which was apparently none of the above.”

That does not negate the fact that she has a mental health condition; it simply does not tick the markers on that sheet. The DWP tick-box system does not seem to account for that at all, nor for people who live with long-term chronic health conditions that fluctuate between good days, bad days and unimaginable days.

Donna has faced an extremely difficult few years trying to cope with severe depression. She has outlined that on one day she can be great and on another she is simply not. I take the point that the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) made; I know it comes from a position of experience, and I greatly appreciate his expertise, but the fact is that Donna has been working in the mental health sector, so she has huge insight into her condition. She knew the only way she would get better would be by taking time and allowing herself to heal, which has taken longer than she had hoped, but now that she has returned to work, she has to fight to keep her personal independence payment, which has allowed her to stabilise her life.

I mentioned this case in a debate last week. Donna recently went back to work on very reduced hours, and through the personal independence payment, she was able to effectively self-manage her condition, meaning that she can lead a meaningful and purposeful life, return to work and provide for her family. Given the presence of her symptoms, that is only possible through the personal independence payment, which she is now being denied because the fact that she returned to work has been held against her. She exactly fits the purpose of those benefits and the criteria set out, but her claim was reassessed and, as a direct result of returning to work, she is no longer entitled to them.

It seems that all the valuable support Donna received over the last three years, combined with her self-determination, is now in jeopardy because, on the day of her PIP assessment, she was:

“well kempt, behaved normally, maintained eye contact and had good insight into my illness”.

Those are the assessor’s marks. They have decided against the criteria that she is no longer eligible for a personal independence payment, despite the fact that, as I am outlining, she relies on it and it has helped her to get back to work, which I believe is ultimately what the Government want. It is counter-intuitive. Healthcare professionals appear to be carrying out assessments without prior knowledge of how mental ill health works.

[Dr Lisa Cameron (East Kilbride, Strathaven and Lesmahagow) (SNP)]

My hon. Friend is making some extremely valid and excellent points, and I thank her for securing the debate. Does she agree that there is a real issue for people whose mental ill health, and perhaps some of the symptoms of it, such as paranoia or severe depression, mean that it is extremely difficult for them to even go to an assessment, because they feel the system might be against them, or they are just not well enough to get there? They are then penalised, and have their benefits taken away when they are very much in need of them, and have been very ill for a long time.

[Angela Crawley]

I could not agree more with my hon. Friend, and with the comments from the hon. Member for Ashfield (Gloria De Piero) about the individual who prepared themselves for an assessment, only for the assessor not to turn up. These assessments are really distressing, and they do not take into account the condition that the person being assessed has, or the impact that the assessment might have. Another of my constituents, Denise from Hamilton, was denied assistance for bipolar disorder because, as the report repeatedly stated, she is not manic all the time or on most days. How does one assessor even know that?

The idea of requiring assistance during periods of mania completely misses the point about the problems that Denise faces. The report ignores the depressive cycles that follow, and her struggles to find a measure of stability. That is a reckless approach, as she would be sent into a manic state if she were not supported, or if she tried to live the way many of us without a disability take for granted. Some of the things that have triggered a manic state in my constituent over the years would wash over most of us without her condition, but that is why the condition is extremely harrowing and distressing for those who have it. Simple things such as preparing for Christmas or a family wedding, stressful news events such as the Grenfell Tower incident, wider health issues such as the menopause, and changes to Denise’s medication for bipolar disorder are all things that have exacerbated her condition. Additionally, she has sometimes entered into mania for no apparent reason. In other words, the condition is out of her control.

I have heard many reports of assessors using very inappropriate language during assessments for people with mental health problems. Several people, including constituents I have mentioned, have told me that when discussing suicidal thoughts, they have been asked bluntly, “Why didn’t you kill yourself?” I do not know what that adds to the assessment, or what it does to a person to be asked that, but this point has been repeated by many of my constituents. When they have discussed suicidal ideation, they have been asked by the assessor, “Well, why didn’t you kill yourself?” I cannot say why they have been asked that.

[Dr Poulter]

Will the hon. Lady give way?

[Angela Crawley]

I will if the hon. Gentleman is going to say something useful.

[Dr Poulter]

I thank the hon. Lady for giving way; she is being very kind. In relation to getting a full picture of suicidality, there are sometimes protective factors that stop people wanting to take their own life. For example, they may have children. There may be other factors in their life that mean that they would not want to go through with the act of ending their life, even though they are having fleeting suicidal thoughts. It is relevant to a clinical examination or history of a person to work out what protective factors there may be, and why it was that, even though they were feeling very bad, very low, and having those thoughts, they did not want to follow them through. I just wanted to make that clinical point to the hon. Lady; it may be helpful for her constituents.

[Angela Crawley]

That would be absolutely fine if the assessor had that level of medical qualification and experience. The point is that they do not. It is fine for a doctor to say that they would ask those questions, and of course any doctor reasonably would, but that is not how this has been delivered. It has not been asked by a trusted medical professional such as a doctor, psychologist, psychiatrist or other professional with the correct experience and understanding of how to handle the situation, the follow-up aftercare or anything that comes with it. The assessor is an individual sitting with a form; it is not the same experience, so I appreciate the hon. Gentleman’s point, but that is just not how it works in reality.

[Debbie Abrahams (Oldham East and Saddleworth) (Lab)]

The hon. Lady is making a very powerful speech. Are not DLA and its successor, PIP, meant to be about supporting disabled people with the extra costs that they face, which are about £560 a month? This system fails to recognise the real injustice that disabled people are experiencing, and unfortunately the Government are just not addressing that.

[Angela Crawley]

I completely agree. The point is that mental illness is a disability—that is what we have argued in previous debates—and should be recognised as such and handled appropriately. I am grateful for the point made by the hon. Member for Central Suffolk and North Ipswich, but we are not having this debate because there is an issue with the healthcare system; I am arguing that there is an issue with the practitioners in the Department for Work and Pensions.

The question to which I have referred has been asked without any follow-up, without any understanding and without the qualification and experience to handle it appropriately. I just cannot understand how it is appropriate or why it is necessary for the assessor to ask that. The ultimate fact is that it can be devastating for people with suicidal depression to have to justify such a dark thought; it can shake the foundations of their wellbeing and make them question their worth. It is not uncommon to hear from people that their personal independence payment or work capability assessments have made them feel worthless. It is not uncommon to hear that from my constituents; indeed, it is all too regular. That is why I am raising this matter with the Minister.

Since 2011, assessors are meant to have had, as part of the assessment process, access to a mental function champion or mental health champion for support and training. I am not sure whether that is working in practice, which is why I urge the Minister to look at it. In not one of the cases that I have dealt with regarding mental health problems has a mental function champion been used. That prompts the question: if the training and capacity are there, why is that not being used by the local DWP jobcentre staff? Why is it not being used to assess people appropriately? Why are assessors not using the support that is available to them if it is in fact there, provided by the Department for Work and Pensions?

I have made challenges in a number of cases in which some support for the assessor on mental health issues would have been appropriate, yet such an intervention has never been used. I have had trouble trying to find concrete figures for how many mental function champions there are across the service and what their role is. I would be grateful if the Minister could enlighten us on exactly what the mental function champions are supposed to do, what role they are supposed to play in the assessments, and how their effectiveness is being measured, because ultimately I was unable to get relevant or accurate statistics from the Department outlining how well that function is being used. If it is there and not being used, it seems that assessors are doing a disservice to the individuals who come face to face with them every day.

When someone is found fit for work but in fact is not, they need to go through the arduous process of appeals. For people with a depressive or other mental illness, that process is extremely difficult and can exacerbate their symptoms. For some, the process is too daunting and they will simply go without the support that they need. I can only imagine the number, because we will not have accurate statistics for how many people go without as they are unwilling to go through that process. I do not believe that that is the right approach to mental illness—or to public expenditure; it would save the Government time and money if assessments were correct, and the correct benefits were awarded at the first stage, in the first instance. The fact that people are having to go through the appeals process and decisions are being overturned at the mandatory reconsideration stage tells us that there is something wrong with the system that could be fixed.

Not only is this a waste of resources for the Department for Work and Pensions and our courts system, but it depletes the mental resources of people who do not have the energy to spare to go through the process. I believe that, ultimately, discrimination against mentally ill people is built into the whole culture of this system. If people disagree with that, they can just ask the High Court. The Government were found in 2018 to have discriminated against mentally ill people in the High Court ruling on regulations that meant that people who were unable to travel for reasons of psychological distress were debarred from the enhanced rate of the mobility component of personal independence payment.

I do not even know where to start with that. If someone has identified under the previous, legacy system that they are unable to travel or have limitations, and then that is undermined in the new system, that seems counter-intuitive. There is surely a better way of operating. The transition from DLA to personal independence payment has been anything but smooth; in fact, there are still flaws and errors in the system. That is all that I am trying to get to here. I really want the system to work better for people, because ultimately I would rather not have to deal with individuals having this horrible experience every day. They should not have to come to me to get things improved; the system should just work better.

The regulation to which I referred was introduced in March 2017 without any stakeholder consultation. I urge the Minister to reconsider that. There are mental health charities and experts outside the House who would be able to provide the relevant and necessary information to the Minister, if she were willing to hear it. That civic engagement would get things correct for those who have used the service and had an adverse experience; it could only enhance and improve the experience.

The High Court ruling represents just a small part of the benefits system, but I think that it represents well the Government’s approach to people with mental health problems. The personal independence payment system, contrary to the Government rhetoric, was designed so that fewer people would be eligible for it than were for the legacy benefit of DLA. If the entire concept and design of a system is to get more people out of the system, it is not really doing what it was designed for, which was to help people. It just seems ridiculous that we are working to these arbitrary targets; that is the only way I can understand this. If we are trying to reduce the number of people on the benefit, even if there is no reduction in the number of people who need the support, ultimately we are just letting people fall through the net. That is a dereliction of our duty of care to the people we serve.

One quarter of people claiming DLA for mental health conditions do not qualify for PIP when reassessed, so they lose the support that they need.

[Andrea Jenkyns]

I welcome a lot of the comments that the hon. Lady has made. I do feel that, as a society and as a Government, we still have a long way to go. However, does she acknowledge that mental health funding has reached record levels? We are talking about £12 billion of funding. Does she at least welcome the fact that the Government have now made big commitments to mental health funding?

[Angela Crawley]

On the one hand, I wholeheartedly agree that any additional funding for mental health will always be welcomed, because we are more aware of the condition and its lifelong effects, but ultimately why are we throwing money against the wall, when at the other end of the process people have to undergo a horrible and unnecessary experience? Join the dots: to improve the health service, improve the service in another Department that gives people the financial support they need. If improvements can be made through one Department, that should be done for another. I have spoken for longer than I intended, and a lot of other hon. Members want to speak, so I will press on.

The Government need to rethink their approach to the needs of people making benefit claims. They must be cognisant of the effect of mental health. Assessments must be more in line with best practice on mental health, so I ask the Minister to meet charities and organisations calling for reform of the benefits system.

I do not know how else to convey to the Government how much I just want to make the system better. I am not trying to make political points for the sake of it. There are flaws in the system, and I would like to improve it. I would like to give as many hon. Members a chance to speak as possible, so I end by quoting from the film “I, Daniel Blake”, because I think it captures this issue perfectly.

“I am not a client, a customer, nor a service user… I demand my rights. I demand you treat me with respect… I…am a citizen, nothing more, nothing less.”

In this day and age, and in this process, it is easy to refer to people as constituents, clients, service users or customers, but we forget that they are just people who ultimately rely on our support. Most people would not chose to rely on that support, especially under the arbitrary measures of the system, which are completely off-putting and attempt to reduce their reliance. People do not tend to want to rely on the state. Every day, my constituents are left feeling demoralised, degraded and ignored. These people elected us to represent them, and we must do more and do better, because at the moment it is simply not good enough. I want to do the best I can for my constituents, and I would not be doing that if I did not call on the Minister to improve this service.

--- Later in debate ---

[Angela Crawley]

I thank the Minister for her kind and compassionate words. It always comes across as if she genuinely cares, and I believe she does, but what I say to her is this: do not be another Minister who passes through the Department and does not address these problems. They need to be dealt with. It is fine saying that on paper the stats look good and people are fine with them, but if one person goes through the process and does not get the support they need, it can be life-changing or life-ending for them, and I want to see that it is life-changing, not life-ending.

Question put and agreed to.

Resolved,

That this House has considered mental health and the benefits assessment process.