Welfare Reform and Health Impact Delivery Group
Health impact of welfare reform on health and NHS services in Scotland
1. Introduction
1.1 This paper reports on an impact assessment undertaken on specific changes to welfare benefits included in the UK Government’s welfare reform programme. It focuses on the impact on health, NHS primary care and NHS secondary care services in Scotland.
1.2 The impact assessment was carried out to support the development of an action plan for the Scottish Government’s Welfare Reform Health Impact Delivery Group (HIDG). The assessment was undertaken by members of the HIDG and the Scottish Public Health Network (ScotPhn). Participants included representatives from the NHS, third sector, local authorities and Scottish Government.
2. Process
2.1 The participants worked in small groups and taking each benefit separately identified the positive and negative impacts on health and NHS services (summaries available in appendix 1). To identify the impacts, participants used published and unpublished evidence and anecdotal reports (appendix 2).
2.2 This impact assessment was not a research project rather, in an extremely tight time scale, it pulled together formal and informal evidence in a structured way to enable the HIDG to develop an action plan. This plan will inform and support NHS boards and partner organisations in preparing their own strategies to support patients and NHS services to respond to welfare reform.
3. Impacts
3.1 Carrying out the impact assessment was judged to be a useful and productive exercise not least because it soon became evident that most of the impacts were similar across all benefit changes.
3.2 The population groups that will most be affected by the welfare reform programme are disabled people, people with long term health conditions, people with learning difficulties, households with children, women, lone parents (90 per cent of whom are women), larger families, older people, workless households and those in low paid work of more than 16 hours per week. The cumulative impact of welfare reforms on disabled people was of particular concern
3.3 In general it was concluded that supporting working age people to move into and progress in good quality employment will have a positive impact on health, narrowing of health inequalities and support the recovery from illness or disease therefore reducing demand on primary and secondary care services. However concerns were raised about the barriers disabled people continue to face in securing employment opportunities and the problems many people experience in trying to secure additional employment hours in the current economic climate when many new job opportunities are low paid and part-time.
3.4 The potential impact on health was closely linked to concerns about increases in levels of poverty and loss of income for the population groups identified, importantly this included both people who were out of work and in-work. For example the Scottish Government has reported that the 1% uprating of benefits will affect two and a half times more people in work than those out of work, in addition the DWP’s own impact assessments have found that approximately 35% of those currently eligible for Disability Living Allowance will lose out under the new system of Personal Independence Payments; they also estimate that in relation to Universal Credit around 200,000 households in Scotland will have higher entitlements (£25 more per week on average) and around 170,000 households will receive less (£19 less per week on average). It was generally agreed that this reduction in income and potential increase in homelessness caused by changes to housing benefit were likely to result in a widening of health inequalities in Scotland and an increase in levels of poor health associated with poverty, disadvantage and social isolation. In particular poorer mental health and increased risk of self-harm and suicides, increased risk of cardiovascular disease and respiratory illness, poorer nutrition and diet related health problems, increase in drug and alcohol dependency, worsening of mental health and well-being in children, increase in incidence of child protection cases and violent crime (including gender based violence) and increase in sexual health problems including increase in teenage pregnancy and sexually transmitted diseases are expected.
3.5 The potential impact on primary care services was mainly identified in terms of increased demand for services due to poorer levels of health associated with poverty and disadvantage (see above) and increased levels of anxiety caused by the changes to the new welfare benefits system. It was agreed that increased demand would not only be experienced by GP’s and practice based staff but also community nursing staff including CPN’s, health visitors, district nurses and learning disability teams. It is expected that there will be an increase in GP consultations focussing on the patient’s social and economic concerns rather than medical ones.
3.6 It was recognised that primary care will face further increased pressures due to demands for evidence to support claims for welfare benefits including Employment Support Allowance (ESA), Personal Independence Payment, Discretionary Housing Allowance, Scottish Welfare Fund and access to passported benefits. Given the experience of the ESA Work Capability Assessment and number of appeals arising through this process, it is expected primary care, and GP’s in particular, will see an increase in number of patients appealing welfare benefit decisions made by the DWP and local authorities. It is likely these patients will need additional support from GPs and primary care teams in response to increasing levels of stress and anxiety caused by the appeal process, as well as additional medical evidence to support their appeals.
3.7 Due to an increase in demand for services and incidence of poorer levels of health it is expected that GP practices and primary care services, particularly in areas of deprivation, will see a rise in costs associated with diagnostic testing, prescribing and treatment programmes.
3.8 Through the impact assessment it was clear that GP practices and primary care teams had a key role to play in providing patients and carers with information about the welfare benefit changes and the application process. Also primary care should increase its knowledge of and relationship with the third sector to make appropriate referrals to welfare rights advice, support groups, cooking groups, food banks, credit unions etc.
3.9 The potential impact on secondary care services was more challenging to identify in this impact assessment although increases in diseases associated with poverty are likely, in the longer term, to impact on secondary care services. Poverty also impacts on recovery from health conditions. However it was agreed that there was likely to be an increase in accident and emergency admissions, in-patient psychiatric care and requests for medical evidence to support applications or appeals for welfare benefits. It was felt that secondary care had a role to play in providing patients and carers with information about the welfare benefit changes and the application process, as well as information about the third sector particularly in relation to gender based violence, welfare rights advice, food banks, support groups etc.
4. Conclusion
4.1 Finally, as outlined above, the HIDG will now take the lead in developing an action plan in response to the impact assessment. The action plan will take into account the mitigating action already being developed in some NHS board areas. As part of this action plan, it will identify how the impact of welfare reform on health and NHS services will be monitored. It will also provide information for NHS boards on numbers of patients that are likely to be affected by welfare benefit changes by analysing figures available from DWP. Where possible the HIDG will also identify the impact that welfare reform will have on HEAT targets. In May 2013 it will report on welfare reform and health inequalities to the Scottish Government’s Ministerial Task Force on Health Inequalities.
Acknowledgment
Many thanks to Jackie Erdman, NHS Greater Glasgow and Clyde for writing up many of the impact assessment reports in appendix 1.
Kate Burton, Scottish Public Health Network; 28 February 2013
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Appendix 1 Impact assessment summaries
Benefit Change Employment Support Allowance
Population Group / Potential impact on health / Potential impact on primary care / Potential impact on secondary careDisabled people (includes physical disability, learning disability, sensory impairment, long term medical conditions, mental health problems)
People with fluctuating health conditions
Working age people
People who are not working
People living in poverty / people of low income / Positive - Supporting working age people with the physical and psychological capability to move into and progress in good quality employment will have a positive impact on health, narrowing of health inequalities and support the recovery from illness or disease. / Reduces demand on primary care services / Reducing demand on secondary care services
As above / Negative – worsening of and increase in mental health problems due to application process, reassessment process and appeals process
Increase in incidence of suicides/self harm due to ESA application and appeals process and WCA
Worsening of health related behaviours including alcohol consumption and smoking due to increased levels of stress and anxiety because of ESA application and appeals process
WCA inadequate at assessing fluctuating health conditions therefore people may be assessed as ‘fit for work’ but their health may worsen in some employment situations
Approx 30% IB claimants invited to be reassessed for ESA lost in the process therefore likely to be at risk of poverty, homelessness, isolation and exacerbation of health conditions etc. / More GP consultations for ‘social/economic’ reasons.
Increase in demand for GP and primary care appointments
Increased bureaucracy for primary care teams and GP’s in terms of providing evidence for ESA applications and appeals
Increased costs associated with diagnostic testing, prescribing and treatment programmes.
Increased pressure on GP’s and primary care to provide support for those being assessed or appealing ESA decisions
Increased pressure on primary care teams to be well informed about welfare benefit changes and what they can do to support patients affected.
Increase demand on vocational rehabilitation services
Increase demand of support services working with primary care including welfare advice services, third sector mental health support groups etc.
Regular reassessment of claimants means ongoing pressure on primary care / Increase in accident and emergency admissions due to mental health conditions, suicide and self-harm
Increase in demand for psychiatric hospital beds.
Increased pressure on secondary care to be well informed about welfare benefit changes and what they can do to support patients affected.
Regular reassessment of ESA claimants means ongoing pressure on secondary care
Carers / May lose carers benefits if the person they care for does not qualify for ESA. Leading to reduction in income, increase in poverty. Potentially leading to health problems due to poverty.
Benefit Change Disability Living Allowance/Personal Independence Payment
Disabled people (includes physical disability, learning disability, sensory impairment, long term medical conditions, mental health problems)
People with fluctuating health conditions
Working age people
People living in poverty / people of low income / Increase in stress and mental health problems caused by the reassessment process.
Worsening of health conditions and increased risk of morbidity caused by reassessment process.
Reduction in or loss of benefit will potentially result in poverty leading to worsening health conditions associated with fuel poverty, health related behaviours (alcohol, smoking etc) and diet related health problems. Reduction in or loss of benefit may result in social isolation and loss of social connectedness, increase in neglect.
Reduction in or loss of benefit may result in having to cease work or reduce hours due to loss or reduction in availability of transport.
Lack of long term PIP awards will contribute to claimant’s levels of anxiety especially when their claim is being reassessed.
Anxiety levels likely to increase due to having to undergo a health assessment to claim PIP which is similar to the WCA. / Increase in workload due to GP’s and primary care teams being requested by patients to provide evidence to support claims for PIP.
Increasing pressures on GP’s and primary care teams as they may be asked by patients to accompany them to PIP assessments.
More GP consultations for social /economic’ reasons.
Increase in demand for GP and primary care appointments
Increased pressure on primary care teams to be well informed about welfare benefit changes and what they can do to support patients affected.
Increased costs associated with diagnostic testing, prescribing and treatment programmes. / Increase in accident and emergency admissions due to mental health conditions, suicide and self-harm
Increase in demand for psychiatric hospital beds.
Increased pressure on secondary care to be well informed about welfare benefit changes and what they can do to support patients affected.
Regular reassessment of PIP claimants means ongoing pressure on secondary care.
Increased costs associated with ambulance transport
Carers / If PIP claim turned down this will impact on any Carers Allowance received by the claimant’s carer and their wider family.
Family income will reduce and carer will be unpaid.
Carer will have to move onto JSA and seek employment even though their caring responsibilities will still exist.
In this situation, carer and family likely to experience increased levels of stress and anxiety, and have less money to spend on utilities, food etc resulting in increased levels of fuel poverty, poor diet and social isolation.
Benefit Change Benefit Cap and 1% uprating of benefits
Families, children, young people
Disabled people (includes physical disability, learning disability, sensory impairment, long term medical conditions, mental health problems)
People with fluctuating health conditions
Working age people
People living in poverty / people of low income / Increased levels of mental and physical health problems associated with poverty and disadvantage. In particular health conditions associated with fuel poverty, health related behaviours (alcohol, smoking etc) and diet related health problems.
Increase in social isolation and loss of social connectedness. / Increase in demand for consultations due to a rise in poverty related health conditions.
Increased costs associated with prescribing, diagnostic testing and treatment programmes.
Increased pressure on primary care to be well informed about welfare benefit changes and what they can do to support patients affected. / Increase in accident and emergency admissions due to mental health conditions, suicide and self-harm
Increase in demand for psychiatric hospital beds.
Increased pressure on secondary care to be well informed about welfare benefit changes and what they can do to support patients affected.
Benefit Change Housing Benefit - Under occupancy Rules