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Lesley Cullen is a social policy officer at Citizens Advice with a long-standing interest in how people with serious illness manage their lives, including older people and the terminally ill. She has co-authored a book on terminal care and written a handbook on the work of volunteers.

Billed as a comprehensive programme to tackle stigma and discrimination, the Social Exclusion Unit's recent Mental Health and Social Exclusion report came with an ambitious 27-point action plan attached.

Citizens Advice had awaited the report, published in June, with high hopes. Our national network of advice bureaux help thousands of people with mental health problems resolve difficulties with benefits, debt, housing, employment and legal matters. But while the Social Exclusion Unit's programme is a welcome step towards breaking the cycle of deprivation and exclusion associated with mental ill-health, it misses important areas of concern.

The programme will be taken forward by the National Institute for Mental Health in England, as outlined in From Here to Equality,(1) and backed by £1.1m in the first year. But without further guaranteed funding it is hard to believe it will have real impact. And without further changes to the Disability Discrimination Bill to make it easier for people to bring cases of discrimination on grounds of mental health, that impact is likely to be further diluted. The proposal to remove the need for mental illness to be "clinically well recognised" addresses only one of the barriers.

There are other serious omissions. The report presented a real opportunity to tackle the enormous difficulties people with mental health problems face in dealing with the benefits system and handling consumer affairs. By sidestepping these issues, it fails to create the building blocks of positive experience when people are unwell which might help their recovery.

Out of the Picture,(2) Citizens Advice's own report on mental health and social exclusion, published in April, drew on evidence from some of our 100 specialist mental health projects around the country and more than 350 advice bureaux. It found that discrimination in the benefits system, consumer affairs and the workplace, along with a general lack of support, excluded people with mental health problems and undermined their ability to cope.

The benefits system should provide financial support and underpin security when people with mental health problems are unwell and unable to work. But evidence from advice bureaux shows that too often it does just the reverse.

Only 18 per cent of people with mental health problems are in work - the lowest employment rate of all disabled groups. Most have to rely on benefits, putting them among the poorest people in the UK. They are up against a benefits system that takes no account of their needs or the difficulties they face in managing everyday affairs when they are unwell.

Unsympathetic treatment by some doctors and a system that focuses on physical symptoms and disabilities prevent many mentally ill people getting the benefits they are entitled to. The constant reassessment of claims can result in significant breaks in income and almost inevitable debt.

Nor does the benefits system take account of fluctuating medical conditions, or make allowances when people are unable to comply with complex procedures and time limits. In 2003, nearly 48 per cent of appeals against the refusal of incapacity benefit were successful,(3) indicating there is a great deal of room for improvement. But many more people are deterred from appealing at all because of the time, stress and loss of income involved.

These difficulties add to stress, frequently exacerbating people's conditions, and even leading to hospital admission. For example, a citizens advice bureau in Berkshire recently helped a client appeal against a decision to stop his incapacity benefit after many years. He had been deemed capable of work, despite his psychiatrist's insistence that he had long-term mental health problems. The cut in his benefit income and worry about the appeal led to a relapse, and he was admitted to hospital under section 2 of the Mental Health Act 1983. This is why Citizens Advice has called for a major review of the benefits system into how performance at every level affects experience and outcomes for people with mental health problems.

It is worrying that one of the indicators the Social Exclusion Unit proposes to use to monitor progress will be a reduction in the number of people receiving incapacity benefit on mental health grounds. Measuring income growth for people with mental health problems and the number in paid work will indicate progress towards the government's objective of getting people off benefit and into work, but counting numbers on incapacity benefit may send the wrong message to those assessing eligibility, making it even more difficult for people to claim benefit.

People with mental health problems also encounter serious difficulties in being effective consumers and getting a good deal, particularly with financial services. Many who come to citizens advice bureaux are in debt. One such was a lorry driver diagnosed with clinical depression. He thought his debt of £9,000 was covered by payment protection insurance, but his policy did not provide cover for events caused by mental health problems.


People with mental health problems face unacceptable barriers to obtaining and claiming on insurance. Many who thought they were protected from loss of income by insurance cover find themselves left high and dry when companies refuse to pay out on claims involving mental illness. The Association of British Insurers should review its good practice guidance on compliance with the Disability Discrimination Act 1995 to ensure the industry is not unreasonably excluding people with mental health problems from obtaining cover and making claims.

People with mental health problems are also particularly vulnerable to high-pressure sales methods and offers of easy credit that can very quickly lead to unmanageable debt. Too often, creditors respond with heavy-handed debt collection instead of fair and sympathetic treatment.

The rare opportunity presented by the Mental Capacity Bill should be used to improve consumer protection rights and remedies, so that contracts can be struck down if they are made during a period when a consumer with mental health problems is ill.

Comprehensive financial advice is an essential element of support for people with mental health problems. The Social Exclusion Unit's plan for advice and support to be built into care programmes and made available through "vocational and social support" in primary care is welcome, but financially over-stretched services will have the lead responsibility here, so these new services may lose out.

A growing bank of independent research shows that advice bureau services in health care settings can have a beneficial impact on people's health, with direct impacts on health inequalities such as access to financial benefits and housing, and indirect benefits in self-esteem and well-being.

Health professionals value the advice services because they set them free to concentrate on clinical matters rather than social problems. Recent evaluation of the Better Advice Better Health in Wales project,(4) which provides a citizens advice bureau service in a primary care setting in each local authority in Wales, found that targets were exceeded, with positive results for both clients and primary health care teams.

The Social Exclusion Unit report presents a unique opportunity to make a real difference to the daily lives of people with mental health problems. But exclusion needs to be tackled on all fronts, including benefit and consumer issues, if the many difficulties facing this group are to be surmounted.

Abstract   

This article looks at the programme for action proposed by the Social Exclusion Unit in its Mental Health and Social Exclusion report. It highlights shortcomings on the basis of evidence from citizens advice bureaux working with people with mental health problems. Particular issues are failings in the benefits system, difficulties created by a competitive market and the need for financial advice early in illness.

References   

(1) From Here to Equality: A Strategic Plan to Tackle Stigma and Discrimination on Mental Health Grounds, 2004-2009, National Institute for Mental Health in England, 2004 

(2) Out of the Picture: CAB Evidence on Mental Health and Social Exclusion, Citizens Advice, 2004 

(3) Quarterly Appeal Tribunal Statistics, June 2003, Department for Work and Pensions 

(4) Bangor University, awaiting publication

Further Information   

• Out of the Picture, available from Citizens Advice, phone 020 7833 7055 or download from www.citizensadvice.org.uk  
• Mental Health and Social Exclusion, Social Exclusion Unit report, Office of the Deputy Prime Minister, 2004   
• Better Health, Better Wales, from www.wales.nhs.uk/publications/greenpaper98  
• Michael Young and Lesley Cullen, A Good Death: Conversations with East Londoners, Routledge, 1996  
• Lesley Cullen, The Use of Volunteers in Home Care Services for Terminally Ill People, King's Fund, 1998  
• Mind: www.mind.org.uk  l Rethink: www.rethink.org.uk
  

Contact the author   

E-mail lesley.cullen@citizensadvice.org.uk