Of Little Benefit

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

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

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

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

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.


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.


(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

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