Is Our Welfare System Fit For Those With Severe Mental Illness?

In 1942 the Liberal MP William Beveridge authored his landmark report outlining his vision of welfare reformation for the United Kingdom. What followed in the post-war reconstruction was the birth of the NHS and a national system of benefits to provide “social security” from cradle to grave. Beveridge’s aspiration was that every British Citizen could receive this help including the unemployed and the homeless. Of course, the sick would also be cured. Yet Beveridge admitted that, “However comprehensive an insurance scheme, some, through physical infirmity, can never contribute at all and some will fall through the meshes of any insurance.”

“Falling through the meshes” has become the reality for many people over recent years with supposed reforms to the benefits system being introduced in a way seen cynically by many as a deliberate ploy to deter those with serious medical conditions from accessing the assistance they so desperately need. This bleak and unforgiving landscape, at times impossible to navigate, was poignantly portrayed in the widely acclaimed yet sometimes heartlessly maligned film “I, Daniel Blake”.

It would seem that, even more than those with Beveridge’s “physical infirmity”, people with serious mental illness are vulnerable to falling, or perhaps actually being pushed through the meshes. This has been extensively reported upon over the last few years and some of those affected have provided powerful personal testimony.

Yet there are others whose voices remain unheard. I am a consultant psychiatrist working in the Assertive Outreach Team in Leeds. I support patients with overwhelming psychosis which at times dominates their lives. The people I see often do not consider themselves to be unwell and they are unable to appreciate that the voices that they hear or the persecution that they flee are anything other than entirely real. Because for them, they are.

Psychosis is of course different for everyone that lives with it but the demons that some wrestle with are far from metaphorical; for some these horrors are seen and heard and the fear that they evoke is terrifying. Medication works to a degree but faced with perpetual dread many I see seek temporary sanctuary through alcohol and street drugs. Sadly this invariably adds to the intensity and the chaos. Because they don’t consider themselves to be unwell most patients referred to me have previously deliberately avoided psychiatric services and rejected all forms of treatment. However, the risks in this group can be high and as a consequence they have usually had repeated enforced hospitalisations. But with intensive support, often over an extended period, we try very hard to establish trust, to maintain hope and to interrupt this harmful cycle of institutionalisation.

An essential part of helping these individuals to rebuild their lives is ensuring that they have the means with which to do it. Since the introduction of Personal Independence Payments (PIP) in 2013 however, our staff have been spending an ever-increasing amount of time supporting patients to access the benefits they are entitled to. Simply beginning this journey with this group can be a challenge as even the promise of more money is not enough to persuade some patients who deny having any illness that they are legitimately entitled to benefits. Some would rather live in extreme poverty than make claims they consider to be fraudulent.

And when this barrier has been overcome the tortuous path ahead starts to reveal itself. For someone bombarded with almost continuous psychotic experiences even seemingly simple tasks can be difficult. And the tasks involved in claiming benefits are far from simple. From completing the complex application forms to attending the assessments, which are sometimes distant from home, the odds are stacked against a person who struggles to concentrate and who is often too fearful of what malicious harm may befall them to venture outside. Then, there is the “medical evidence”; again lengthy and complex forms sent to multiple team members which replicate sometimes highly personal information, some of which seems wholly surplus to requirements. Yet without these reams of reports and risk assessments it is definitely my impression that applications are more readily rejected.

The assessments themselves cause serious consternation, conducted as they are by individuals who sometimes have questionable mental health knowledge and experience. At times they are adversarial and at others they are highly selective in their interpretation of the extensive information we have supplied. The perception of accompanying staff has sometimes been that the aim of the assessors has been to find reasons to justify their rejection of applications rather than to afford the patient a fair hearing.

Finally there are the consequences of rejection. The hardship, the food banks, the sanctions and the interminable delays for appeals. These are not sensationalist devices used by a left-leaning film director to attack the government; they are sadly a harsh reality for some of the most vulnerable members of our society.

So what can be done to address the inequality in the welfare system that faces those with serious mental illness? There is always going to be the issue of ensuring adequate support to patients who need it.Those I see are very fortunate to have the help they do. For many less fortunate, the dearth of community mental health support resulting from a period of vicious austerity, means that they do not have any professionals involved in their care to provide them with guidance or the crucial medical evidence they require.

As for the assessments themselves, the consistent criticism that I hear is that they continue to focus predominantly on physical disability. The people I see may well have the physical ability to prepare food, to manage their toilet needs and to get around. But their ability to focus in the midst of derogatory demonic voices or delusions of persecution by unseen assassins can easily transform these very basics of life into insurmountable challenges. We desperately need better tailored assessments that capture these nuances and look beyond the purely physical to the effects of mental illness on functioning and quality of life.

The World Health Organisation described extreme poverty as “The world’s most ruthless killer and the greatest cause of suffering on earth”. And we know that whether by cause, consequence or both, poverty and social inequality are associated with serious mental illness including psychotic disorders, major depression and alcohol and drug misuse.

But what makes this real for me is that every day I see the effects of these unnecessarily distressing trials on patients and I wonder why a system conceived to alleviate suffering is currently achieving precisely the opposite effect.