Unfair Judgments

‘Any physical or psychiatric disorder can be exaggerated, faked or feigned,’ the psychologists Peter Halligan, Christopher Bass and David Oakley wrote in their introduction to a collection of essays from 2003 titled Malingering and Illness Deception. Medical professionals, researchers and even courts, they went on, were often reluctant ‘to entertain the label or to stigmatise individuals as malingerers’. The book grew out of a conference held in November 2001 at Blenheim Palace, where leading academics, clinicians and civil servants (Halligan was a professor at Cardiff University and later became chief scientific adviser for Wales) set out to challenge the assumption that malingering was unusual. After all, indicators of population health were improving, but the number of people on disability benefits had risen sharply since the 1970s. Was this really the result of a genuine increase in sickness and disability? It was implied that there was an urgent need for more stringent benefits assessments, to weed out the fakers.

In fact there was no convincing evidence of widespread malingering, and there were plausible explanations for the increase in claims: the life expectancy of some claimants had increased, more people were entitled to disability benefits, and there was a lack of suitable jobs for disabled people. But the focus on deception played to the prejudices of the conference’s main backer, a government department founded only five months earlier. The conference, its organisers wrote, ‘would not have been possible’ without funding from the Department of Work and Pensions (DWP) and the ‘enthusiastic support’ of its chief medical adviser, Mansel Aylward, who had already been instrumental in the introduction of major changes to the assessments that claimants had to undergo in order to receive disability benefits. As John Pring shows in The Department, these changes – and others that followed – would ‘lead to countless deaths of disabled people’.

Many governments have talked up the number and significance of false claims. A decade before the Blenheim conference, Peter Lilley, who became secretary of state for social security after John Major’s victory in the 1992 general election, promised to go after fraudsters in a speech to that year’s Conservative Party Conference which pastiched the Gilbert and Sullivan aria ‘I’ve Got a Little List’, sung by the Lord High Executioner in The Mikado:

There’s those who make up bogus claims
In half a dozen names.
And councillors who draw the dole
To run left-wing campaigns.
They never would be missed,
They never would be missed.

Lilley and his civil servants thought disability benefits were a ‘promising area for making economies’, as one departmental memo put it. His welfare crackdown was meant to appeal to voters on low incomes, who had long been primed to resent people on benefits, but Lilley maintained that he was defending the genuinely disabled: the test would ‘protect their benefit against those who abuse it’.

The view that most claimants did not deserve benefits was widespread in the Department of Social Security (DSS). Aylward, a former GP recruited by the DSS in 1985, blamed the growth in disability benefits on credulous GPs, who took their patients’ complaints at face value and wrote them sick notes that entitled them to welfare. Aylward pushed for assessments to be conducted by specialist ‘disability analysts’, who would use ‘more objective methods’. He agreed with the DSS colleague who wrote to him that a new system should put ‘less weight on any letter of support sent by a GP’ and pay ‘more attention to the opinion of the experts, i.e. us!’

Aylward had begun to develop his own theory about disability, which he saw as an alternative to biomedical and social models. The biomedical model treated disabilities as impairments of normal bodily functioning, leading GPs to make diagnoses based on patients’ subjective descriptions of their symptoms. In the social model, developed by disabled activists, disability was regarded as a result of society’s failure to accommodate bodies and minds that didn’t conform to a narrow idea of what was normal. Aylward insisted that both these models framed the disabled person as a ‘passive victim’ who ‘bears little responsibility for his or her incapacity or rehabilitation’. In contrast, his ‘biopsychosocial model’ provided a ‘scientific evidence base’ for welfare reform by taking seriously the role of personal perceptions in producing disability. According to Aylward, most disability benefits were paid out for ‘common health problems’ such as musculoskeletal or mental health conditions. While the initial impairment was often real, poor medical advice and insufficient support meant that claimants came to believe they were incurably disabled; in fact, Aylward suggested, their symptoms were often no worse than the aches and pains experienced by most working adults. GPs and sick notes reinforced the belief that they couldn’t recover, but a specialist functional assessment would be able to identify ‘inappropriate illness behaviours’, motivating claimants to improve their health and return to work.

The All Work Test – which Aylward called his ‘claim to fame’ – was introduced in April 1995. After 28 weeks off sick, a claimant would have to fill in a questionnaire intended to determine their future capacity for work. Their answers would be evaluated by a doctor from the Benefits Agency Medical Service, and just over half of the claimants would be called in for an in-person assessment. Claimants were awarded points according to their difficulty in undertaking daily activities – including walking, lifting and carrying, and bending and kneeling – with fifteen points required to qualify for Incapacity Benefit.

The first known death after a rejected appraisal came within two years. David Holmes had worked as a hydraulic fitter for British Steel in Ebbw Vale until, aged about forty, he had a massive heart attack in 1982. Since then he had spent time on his hobbies – CB radio, choral singing and fishing – supported by a mobility pension. The only exercise he could manage was a short walk round a nearby lake with his dog. In October 1996, Holmes was assessed by a DSS doctor and awarded just seven points, for being unable to walk more than two hundred metres. Picking up a heavy shopping bag gave him chest pain, but he received zero points for difficulties with lifting and carrying. Holmes was forced to return his pension book to the DSS. That November, he wrote to the Benefits Agency, asking how the doctor ‘who I saw for less than forty minutes and who asked the most irrelevant questions’ – including ‘What TV programmes do you watch?’ – had found him medically fit for work. ‘They have never seen me on a bad day on the edge of my bed, trying to get my breath before I can even dress … I fail to see why I should have to risk another coronary and therefore risk my life to further the aspirations of government bureaucrats.’ The next day, while being driven to his local CB radio club, Holmes died after a second massive heart attack.

The local Labour MP, Llew Smith, who knew Holmes, secured a late-night Commons debate on the All Work Test. He said that Holmes had endured ‘a degrading experience, conducted in an uncaring manner’, which had led to his death. ‘Can the honourable gentleman tell me of a medical technique to predict a death from heart disease within five days?’ Alastair Burt, the minister for disabled people, replied. ‘If he can, perhaps we can incorporate it in the test.’ Burt claimed that ‘people with severe medical conditions are dealt with sensitively,’ but many people had stories that called this into doubt. A woman with spondylosis had been left with broken bones after a DSS doctor refused to help her get up following a kneeling test. A woman with arthritis of the spine told her assessor she could not raise her arms, so the assessor jerked them violently above her head and then recorded no significant limitation of movement. Smith told of a constituent who had been made to ‘grovel on the floor at the feet of the examiner’ to test whether she could pick up a piece of paper.

The Labour Party took office a few months later, having curbed its own freedom of manoeuvre by promising to stick to Tory spending plans. A memo from December 1997 described ‘a package of measures that would deliver savings of £1½ billion’ in disability benefits. In response, activists from the Disabled People’s Direct Action Network threw red paint over the gates of Downing Street, calling it ‘Blair’s blood’. Labour’s reforms advanced slowly, in the face of backbench rebellions and efficient campaigning by activists. The government began by introducing means testing and stricter assessments, outsourced to the Anglo-French IT company Sema Group. The day after Labour’s landslide re-election in 2001, it created the Department of Work and Pensions, adding responsibility for employment to the social welfare functions of the old DSS. Alistair Darling, the new department’s first secretary of state, claimed that ‘people on sickness and disability benefits’ were ‘suffering high levels of inactivity’. He promised schemes to ‘give them the self-esteem and confidence they need to hold down a job’. Those who did not step up would be punished with the loss of their benefits: ‘It is not unreasonable to require people to take up that opportunity.’

Re-elected once more in 2005, Labour proposed reforms intended to stop around a million people – more than a third of the 2.7 million claimants – from receiving Incapacity Benefit. ‘Does anyone seriously believe that every year you have 350,000 more people completely incapacitated from any form of work?’ Tony Blair demanded. The green paper published in January 2006 decried the ‘perverse incentives’ – claimants got more cash the longer they stayed on Incapacity Benefit – that ‘trap people into a lifetime of dependency’. It proposed that Incapacity Benefit should be replaced by a new Employment and Support Allowance (ESA), with claimants divided into three groups: a small number ‘with the most severe health conditions or disabilities’ would receive the highest level of payment and wouldn’t be expected to look for work; those whose conditions were less severe would have to do ‘work-related activity’, practice interviews and training in order to receive benefits; everyone else would be judged fit for work. The Welfare Reform Act received royal assent in 2007; ‘We must rip up sick-note Britain,’ the work and pensions secretary, Peter Hain, announced. The All Work Test was replaced by the Work Capability Assessment (WCA), conducted not just by doctors, but also by nurses, paramedics, physiotherapists and occupational therapists. The contract to conduct these assessments, worth £500 million over five years, was granted to a French outsourcing firm called Atos. The WCA finally came into operation in October 2008. Northern Rock had just been nationalised, international credit markets were paralysed and the UK economy was in freefall. Between October 2008 and February 2009, around 175,000 people applied for ESA, of whom around 69,000 (39 per cent) were found fit for work.

After Labour’s defeat in the 2010 election the new coalition government sent Iain Duncan Smith to head the DWP. Almost a decade before, as Tory leader, he had been brought to tears by the poverty he was shown in Easterhouse, a postwar housing scheme on the north-eastern edge of Glasgow. But that was then. Now there was a credit crunch to pay for. Bank bailouts had pushed private sector liabilities onto the public balance sheet; Tory ministers blamed the debt on Labour’s spending while in government on a bloated welfare state and its feckless dependents. The strategy was astoundingly successful in winning over public opinion. George Osborne, the chancellor, evoked a shift worker ‘leaving home in the dark hours of the early morning, who looks up at the closed blinds of their next-door neighbour sleeping off a life on benefits’. In an interview with the Sun, Duncan Smith more prosaically blamed the ‘massive deficit’ on ‘a block of people in Britain’ who ‘have been conditioned to be users of services, not providers of money’. Annual welfare spending was £152 billion – about the same size as the deficit – though almost half of this went to pensioners, who were overwhelmingly Tory voters. Osborne proposed welfare cuts of £11 billion in June 2010 and a further £7 billion the following October; state pensions were protected by a ‘triple lock’ – they increased by whichever was the highest out of inflation, growth in average earnings or 2.5 per cent. In 2011, Duncan Smith introduced a Welfare Reform Bill intended to streamline the benefits system, liberating those supposedly trapped in ‘a permanent state of worklessness and dependency’, once again, to find paid employment. The measures were brutish: a ‘bedroom tax’ on underoccupied social housing, a cap on benefits payments, and a strengthened sanctions regime.

Labour had committed to reassessing all those who were still receiving Incapacity Benefit, but Duncan Smith took this further: the Disability Living Allowance – not a work-related benefit, but one intended to help with the extra costs of disability – would be rebranded for adults as the Personal Independence Payment, and everyone who received it would be reassessed. As Pring points out, these reassessments targeted ‘an entirely different group’. New applicants often had conditions from which they would soon recover, but some existing claimants had received the allowance ‘for many years because of long-term impairments’. The assessment process – a questionnaire followed by an evaluation with a medical professional – soon became notorious. One claimant sat in his wheelchair throughout; his assessor’s report said he was walking around. Another report mentioned a claimant’s weekly shopping trips with her daughter, yet the daughter had lived overseas for sixteen years. A whistleblower said there was relentless pressure on the assessors, who were told to spend 105 minutes on each case: an in-person evaluation plus a review of as many as eighty pieces of written evidence. There was evidence of deliberate efforts to block claims. Eligibility thresholds were tightened: the fifty-metre rule – did a person struggle to walk fifty metres? – became the twenty-metre rule. Secret filming suggested that staff were being monitored in an attempt to keep approval rates low. Assessors were caught describing claimants as ‘parasitic wankers’ and ‘down and outs’, and boasting that they had deliberately ignored evidence.

Between October 2013 and September 2024, nearly 1.1 million people – 31 per cent of those who completed a Work Capability Assessment – were found fit for work and refused disability benefits. More than 1.8 million people who received the Disability Living Allowance had been reassessed by October 2024: 25 per cent had their payment reduced; 8 per cent had it removed; and 4 per cent failed to finish the assessment. The effects – on a group already far more likely to live in poverty – were devastating: according to one study, between 2010 and 2013 the reassessment programme in England was linked to 590 additional suicides.

John Pring’s​ Disability News Service demonstrates the vital role that online media can play in exposing stories that tend to be overlooked by the mainstream press. A disabled person himself, he has dug through archives, doorstepped politicians and undertaken a ‘decade-long freedom of information battle’ with the DWP. He is not alone in the fight against welfare injustices, and is careful to acknowledge the efforts of numerous activists, notably the groups Disabled People Against Cuts, the Mental Health Resistance Network and Black Triangle.

Pring’s book memorialises some of the lives lost. On a university visit, Stephen Carré buys ‘a large, beautiful bear’ for his older sister. Aged seven, Jodey Whiting brings a stray goat back to her grandmother’s house, insisting she wants to adopt it. Errol Graham works on his ‘prized black Mongoose mountain bike, building it up from just a frame’. By 2009, aged 41, Carré is living in one room in his house, possessions ‘piled around him’; he has hardly stepped outside for two years; soon after, he kills himself. Whiting, at 42, is barely able to leave her flat; she is in constant pain and experiencing severe mental distress. Early in 2017, her mother and daughters find her body on the sofa, beside a ‘blue notebook, decorated with a ribbon’, which contains her scribbled thoughts: ‘breathless – bk pain … trying to pay bills … head hurts … I cnt cope no more … debt debt debt.’ In 2018, the 57-year-old Graham, who has grown increasingly isolated, is discovered dead on his bedroom floor; the only food in the flat is ‘two tins of tuna, dated 2013’ and his body weighs four and a half stone. In one room, his relatives find ‘the lid of a shoebox’ containing ‘a pair of pliers and two large molars’. There is also a letter to his benefits assessor, never sent: ‘I’m afraid to put my heating on and sit with a quilt around me to keep me warm … Please judge me fairly. I am a good person but overshadowed by depression.’ Carré, Whiting and Graham had all been found capable of work and their benefits had been stopped shortly before their deaths.

Pring’s account reveals something of the character of austerity: it isn’t so much that the state withdraws from an involvement in people’s lives, but that its contact with them is degraded. Many of the people Pring writes about were in touch with an array of government agencies until they died. But these encounters were characterised by indifference, hostility and suspicion. Whiting’s mother describes a job centre employee who ‘stood at the front door with a security guard’ and decided whether or not applicants could speak to their caseworkers. Asked by her job coach to explain why she had missed an earlier appointment, Faiza Ahmed wrote on a form: ‘I was busy trying to kill myself, drinking non-stop.’ The job coach described this statement as ‘serious’ but not ‘unusual’. After she gave him the form, she left. He did not contact emergency services, and Ahmed killed herself three hours later, on 7 November 2014. The day before she died, she had been sexually assaulted; in her last hours she had contact with at least ten police officers and paramedics. Her family describe her as ‘kind and intelligent’, ‘creative’, a lover of poetry and music. But Ahmed was not a good victim in the eyes of those who dealt with her: she was drunk; she was distressed; years of antagonism from the police had left her cynical and uncooperative. At her inquest, several officers described her as aggressive and confrontational. Her brother saw this as ‘casual racism’: when a young black woman was ‘emotional and upset’ this was interpreted as threatening behaviour.

Ahmed’s death led the coroner to issue a prevention of future deaths notice to the DWP; so did Carré’s death. Recipients are legally obliged to act to prevent further deaths in similar cases. But Pring finds evidence that these notices were being suppressed. Carré’s notice was not disclosed to the Mental Health Resistance Network’s legal team during their court case against the DWP over the discriminatory effects of the WCA; it was not shared with Malcolm Harrington and Paul Litchfield, the physicians who led the independent reviews of the WCA; Duncan Smith claimed he didn’t remember it. Though there were press reports of numerous deaths linked to welfare reforms, the DWP claimed in 2014 that it held no information on these cases. After a freedom of information request, it admitted that since 2012 there had been 49 peer reviews ‘following the death of a customer’; it then claimed it lacked the lawful authority to release them. When it finally did so in 2016, after a protracted legal battle, it turned out that the documents contained repeated warnings about the potential harms of WCAs, and suggested mitigations that were never enacted. These documents had also been withheld from the independent reviews.

Pring spoke to Mansel Aylward, who left the DWP in 2005 to become director of the UnumProvident Centre for Psychosocial and Disability Research at Cardiff University; the centre’s associate director was Peter Halligan, co-editor of Malingering and Illness Deception. Aylward later became the chair of Public Health Wales NHS Trust and was knighted in 2010. He was shocked at what Pring had to tell him. ‘Hundreds of deaths!?’ He insisted that something had gone wrong: ‘I would like to know what the qualifications are of people who are doing an assessment. I want to know what training they had beforehand.’ He promised to follow up with the DWP, but died not long after Pring spoke to him, in May 2024. His obituaries claim that the assessments he pioneered ‘focused on rehabilitation, reskilling and support for people with disabilities’. While Aylward insisted that the quality of assessments was the problem, his biopsychosocial model of disability was cited by David Freud, minister of state for welfare reform under David Cameron, in justification of the government’s planned expansion of benefit reassessments.

The DWP’s long-standing refusal to use information from healthcare providers in WCAs is seen by Pring as a legacy of Aylward’s scepticism about GPs. The sponsorship (until 2009) of the Cardiff centre by UnumProvident, a huge American insurance company, makes clear the close association between the insurance industry, Aylward’s biopsychosocial model – a major focus of his academic research – and welfare reform. In the early 1990s, before Unum merged with Provident, Peter Lilley recruited Unum’s vice president John LoCascio as an adviser, supposedly because of his expertise in assessing disability and illness claims. LoCascio wrote articles with Aylward and spoke at the conference on ‘malingering and illness deception’. Unum sponsored fringe events at party conferences; it hired Peter Dewis, a DWP colleague of Aylward’s, as a director; it petitioned the work and pensions committee to reduce ‘disincentives for disabled people to look for work’. In 2005 Unum was described by California’s insurance commissioner as an ‘outlaw company’ that systematically refused claims; he fined it $8 million and ordered it to reopen 26,000 cases. Michael O’Donnell, who became Atos’s chief medical officer, previously held the same position at Unum. He then had a senior role at Maximus, which since 2015 has carried out WCA and Personal Independence Payment assessments for the DWP.

Pring’s book was published two months after the 2024 election. The new work and pensions secretary, Liz Kendall, condemned the Tories’ ‘divisive rhetoric’ of ‘strivers versus scroungers’. Following the election, in a bid to put ‘transparency at the heart of the DWP’, she published 31 research papers ‘sat on by the previous government’. But these were changes in style not substance. In power, Labour has been hobbled by deciding, as the Blair government did, to follow fiscal rules inherited from the Tories. With growth flatlining, Keir Starmer and Rachel Reeves have chosen to balance the books partly by cutting health-related benefits. According to the DWP’s own analysis, the projected saving of £4.8 billion by the end of the decade – or 0.4 per cent of current government spending – will result in 800,000 people losing an average £4500 per year from their personal independence payments.

Supporters of the cuts emphasise that there has been a sharp rise in the number of working-age people claiming disability and incapacity benefits – from 2.8 million in 2019 to four million in 2024 – which has not been seen in comparable countries such as Sweden and the Netherlands. This is blamed on misplaced incentives built into the UK welfare system, where health-related benefits pay out at higher rates than unemployment, encouraging workers to go off sick – in other words, once again, to malinger. Ministers have raised the spectre of widespread benefit fraud. The Public Authorities (Fraud, Error and Recovery) Bill compels banks to share the financial information of benefits claimants with the DWP. Kendall introduced the bill in Parliament with a promise to ‘every single individual knowingly cheating the system’ that ‘We will find you, we will stop you and we will get our money back.’

Yet the recent increase in welfare spending has only brought the UK up to the same levels found in other wealthy countries: in 2019, the average OECD country spent 1.6 per cent of GDP on health-related benefits for working-age adults; in the UK, this figure has risen from 1.3 per cent then to 1.7 per cent now. A single person over 25 claiming Universal Credit with the health-related uplift receives an annual income of £9715; without the uplift, £4721. According to established metrics, this is the difference between living just above the poverty line and living in destitution. And these figures don’t include the staggering additional costs involved in living with a disability. There is also compelling evidence, ignored by the government, that people in the UK have become sicker since the pandemic: more people are reporting mental health conditions, while working-age mortality rates remain elevated. Severe backlogs in NHS treatment will not have helped matters. In this context, the measures announced by Labour in its recent welfare green paper – which exclude anyone under 22 from receiving the health-related uplift and further tighten eligibility for personal independence payments – seem both arbitrary and cruel.

In September, disabled activists organised the delivery of 650 copies of The Department to Westminster – one for every MP. At least one copy appears to have been read. Appearing before the work and pensions committee in February, Stephen Timms, the minister for social security and disability, interrupted the meeting to offer a brief statement about Pring’s book. While Pring ‘highlights serious mistakes’, Timms said, he ‘doesn’t produce any evidence of the conspiracy that is implied’, namely that the DWP was ‘hiding the evidence’ on welfare deaths. Rather than civil servants being to blame, it was Tory ministers who ‘chose that things ought not to be open’. By that standard, Timms’s own refusal to release reports critical of the DWP since taking over should be a cause for concern. That said, he overstates the power of ministers and underestimates the degree to which attitudes and practices can become entrenched in bureaucracies. DWP officials continue to dissemble when faced with the scale of harm caused by the department, even while pushing out dubious figures to justify the cuts: a recent press release appeared to overstate the increase in incapacity claims by a factor of ten. Labour has shielded the department from serious criticism, expanded its powers and fuelled anti-disabled sentiment with indiscriminate attacks on claimants. Disabled people in cities across the UK have begun taking to the streets. To judge from Labour’s attitude in government so far, the likelihood is that their protests will continue to be met with indifference.