Is Rishi Sunak playing politics with ‘sick notes’ or does the benefits system need to be reformed?

The prime minister has provoked outrage from health charities and groups representing people with disabilities due to his proposed changes to eligibility for social security. Rishi Sunak has said he will end what he calls a “sick note culture” with a new “moral mission” to reform the welfare system if re-elected. Focusing on younger people and the numbers suffering from mental health conditions in particular, he calls the number of economically inactive young people – for whatever reason not seeking work – in Britain a “tragedy”. Pointing out that reforms in recent years have not prevented an increase in long-term sickness, Sunak says: “We don’t just need to change the sick note, we need to change the sick note culture, so the default becomes what work you can do – not what you can’t.”

Because any speech or policy that touches on the most vulnerable in society is bound to be so – but also because Sunak himself wants to confront the issue despite the reaction it’s bound to cause. In his speech, he struck a balanced but unusually sceptical note on mental health assessment, specifically in a work context: “We need to be more ambitious about helping people back to work. And more honest about the risk of over-medicalising the everyday challenges and worries of life.” He added: “The biggest proportional increase in economic inactivity due to long-term sickness came from young people. Those in the prime of their life, just starting out on work and family – instead parked on welfare. We should see it as a sign of progress that people can talk openly about mental health conditions. But just as it would be wrong to dismiss this growing trend, so it would be wrong merely to sit back and accept it because it’s too hard or too controversial or for fear of causing offence.”

Yes. For example, Dr Sarah Hughes, CEO of Mind, said: “We are deeply disappointed. The truth is that mental health services are at breaking point following years of under-investment with many people getting increasingly unwell while they wait to receive support. To imply that it is easy both to be signed off work and then to access benefits is deeply damaging. It is insulting to the 1.9 million people on a waiting list to get mental health support, and to the GPs whose expert judgement is being called into question.”

Mental health is a sensitive issue where campaigners have worked hard to remove stigma and give it the same status as other forms of physical illness. It was a cause that particularly concerned Theresa May as prime minister, and which continues to be raised by Prince William.

He is correct in pointing to the increase in long-term sickness rates among the young, and their impact on employment and the cost to the government in universal credit payments, but whether reforming and tightening eligibility criteria would yield much material change is debatable. For example, taking assessments about fitness to work away from family doctors (who may be too sympathetic) to other “healthcare professionals” might not necessarily lead to a radical change in the numbers ending up on sickness benefit. There is also the danger that “independent” assessment can lead to terrible injustices and suffering. The Atos scandal a decade ago, when assessments were outsourced and sometimes cruelly processed, demonstrates the dangers associated with such a reform; about half of those found fit for work by the Atos company were unable to get a job, including some with terminal conditions.

The suspicion is that in an election year the Conservatives are trying to win the support of voters traditionally suspicious of waste and fraud in the welfare state (which of course exists, but probably always has and will). Nothing new there, then. On the other hand, Sunak makes the perfectly reasonable point that the amount spent on welfare payments for the long-term sick is running at £69bn, ie on benefits for people of working age with a disability or health condition: “That’s more than our entire schools budget; more than our transport budget; more than our policing. And spending on personal independence payments alone is forecast to increase by more than 50 per cent over the next four years. Let me just repeat that: if we do not change, it will increase by more than 50 per cent in just four years. That’s not right; it’s not sustainable and it’s not fair on the taxpayers who fund it.”

Sunak’s proposals are based on implicit assumptions that the cost can be reduced whilst maintaining fairness and protecting the most vulnerable, but that wouldn’t hold if genuine long-term sickness really is growing because the health of many people is generally deteriorating. Genuine factors include: mental health conditions being under-reported in the past; the pandemic leading to more cases of long Covid in people of working age; NHS waiting times making various conditions harder to treat and thus delaying people getting back to their jobs. There can also be a tendency to confuse the daily anxieties of life with mental ill health. More widely, an ageing population will necessarily bring more long-term illness, more hospitalisations, and more people of working age claiming carers’ benefits for looking after a loved one.

The reality is that the leaders of both main parties want to constrain welfare payments and get more people into work to deal with endemic post-Brexit labour shortages, which are holding back economic growth. Both judge the 2.5 million people out of work due to long-term sickness as too high.

Labour concentrates on attacking the government’s record because the Conservatives had 14 years to sort the system out. But on future policy, the parties are in basic agreement. Even the language they both use is sometimes very similar. Here are a couple of examples drawn from Sunak’s speech and the last major one Liz Kendall, shadow secretary of state for work and pensions, delivered in March:

Sunak: “We can deliver the vision for welfare I’ve set out today… and give back to everyone who can, the dignity, purpose and meaning that comes from work.”

Kendall: “I have always believed the benefits of work go beyond a payslip. Having a job and providing for your family gives millions of people across Britain a sense of dignity and self-respect.”

Sunak: “[There is a] growing body of evidence that good work can actually improve mental and physical health.”

Kendall: “Good work is good for mental health. Work can bring pride, fulfilment and purpose.”

Whoever wins the next election, social security will be reformed and, sadly, there will be losers.