‘Britain’s welfare crisis is a health crisis. Labour should treat it like one’

Only 7% of Britons think government should spend less on benefits for disabled people who cannot work. Almost half, 49%, favour spending more, even if that means higher taxes. Among Labour voters, only 5% favour cuts. 

These figures should challenge the welfare debate. Not because Britain has become indiscriminately pro-welfare. We have not. Attitudes towards unemployment benefits remain markedly tougher. The public is making a distinction which Westminster too often obscures: between worklessness and ill health.

For Prime Minister Andy Burnham, this presents an opportunity. He has argued that the social security bill must fall, whilst rejecting crude cuts which push people further into poverty. There is room for both positions to coexist, but only if lower spending is treated as the consequence of successful reform, not its organising principle. 

Britain has a population health problem which increasingly appears on the Department for Work and Pensions balance sheet. More than nine-million working-age people are economically inactive, with long-term sickness now a major cause. This is usually described as a labour-market or welfare problem. As a doctor and health inequalities researcher, I would start elsewhere.

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A rising health-related benefits caseload is vital epidemiological information: reflecting the health, not just the wealth, of our nation. It may reflect worsening mental health, musculoskeletal disease, multimorbidity, delayed treatment, weak occupational health, inaccessible workplaces, or poor housing. These mechanisms differ, but they occur long before a benefit claim is ever made.

Yet, policy repeatedly begins at the end of the causal chain. The claimant is visible; the illness, waiting list, workplace and deprivation that preceded the claim sit across different departments and budgets. Rising expenditure is then observed at the DWP and treated as evidence that the principal problem lies within social security. A caseload is a signal; not a diagnosis.

This matters because ill health is not evenly distributed. Healthy life expectancy differs by almost two decades between England’s most and least deprived populations. Economic inactivity because of long-term illness is also substantially higher in poorer parts of the country.

That geography is not incidental. People in deprived communities develop serious illnesses earlier and spend more of their lives in poor health. A labour market unable to accommodate fluctuating illness converts some of that morbidity into worklessness. An NHS unable to intervene rapidly can turn reversible limitation into prolonged incapacity. Social security absorbs the downstream consequences.

It may compound it. Income is itself a determinant of health. Lower income constrains food, heating, housing and transport; persistent insecurity carries psychological and physiological costs. We can therefore create a perverse loop: illness reduces capacity to work; income falls; support is withdrawn to strengthen the incentive to work; and the conditions required for recovery deteriorate: and the vicious spiral continues.

Personal Independence Payment (PIP) illustrates why precision matters. PIP is not an unemployment benefit. It contributes towards the additional costs of disability and long-term illness and can be received while working. The Timms Review has concluded that the current system is no longer fit for purpose, while preserving the principle of extra-cost support.

Employment does not make disability disappear. A salary does not restore mobility, remove the need for assistance or eliminate the additional costs of impairment. Labour should, therefore, reform social security, but judge that reform clinically as well as fiscally.

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Waiting-list reduction is welfare policy when treatment helps somebody remain in work. Occupational health is welfare policy when early intervention prevents long-term absence. Secure housing is welfare policy when it stabilises health. Workplace adjustment is welfare policy when it prevents illness becoming exclusion. Prevention is welfare policy when fewer people reach working age already carrying avoidable disease. This is where health equity and fiscal responsibility meet.

There are ultimately two ways to make disability cheaper for the Treasury. Government can reduce the prevalence, severity and social consequences of ill health; or it can reduce how much society contributes towards those consequences. The first is generational reform; the second option sweeps the issues under the rug. 

The British Social Attitudes findings suggest the public understands the distinction. Sixty-three per cent identify disabled people as a priority for additional social security spending, even though support for greater disability spending is lower than in 1998. This is not an electorate demanding an ever-expanding welfare state. It is an electorate retaining a distinction between ordinary economic risk and risks people cannot reasonably carry alone.

Burnham should build from that principle. Reform should be judged by whether fewer people become preventably sick; whether those who develop illness can remain in, or return to, good work; and whether people with enduring disability can live without bearing costs they cannot reasonably absorb themselves.

If that eventually reduces expenditure, so much the better. The Treasury saving should be the dividend of a healthier country, not a substitute for creating one.

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