The Work Programme is a policy out of its economic depth

A decent idea born at a time when the jobs were there produces perverse results when they are not.

The Work Programme, the government’s vast welfare-to-work scheme, was supposed to be an engine of good news. It has been cited on a number of occasions by David Cameron as the shining example of radical innovation in a notoriously difficult area of policy and a firm rebuttal to the Labour charge that the government is somehow complacent about unemployment.

Billions of pounds are being made available in contracts to private and voluntary sector organisations in exchange for their expertise in placing benefit claimants in work.

Crucially, the service providers are paid by results – meaning, after a small “attachment fee”, they only get their money when their clients have jobs. People deemed harder to employ – generally those who have been out of work for longer – carry a premium. This is supposed to act as an incentive for providers to concentrate their efforts on the stubborn cohort of the long-term unemployed.  (A weakness in predecessor programmes was deemed to be that providers got paid for finding jobs for people who would have found them anyway and ignoring those who most needed help – the practice known in the industry as “parking and creaming”.)

A second aspect of the Work Programme deemed vital by government and providers is the “black box” approach. This means, in essence, that the Department for Work and Pensions won’t dictate the methods used to place people in work. Providers are meant to innovate and compete. The better formulae – the devices contained in the black box – will, in theory, succeed and their designers can then get more work and make more money. Naturally, the DWP does not (knowingly) tolerate cruel, illegal or fraudulent methods in the black box. The system is meant to drive imaginative, local solutions to a famously intractable problem.

As a theory it could all sound rather splendid: harness market forces alongside the noble ethos of the voluntary sector, underwritten by the DWP budget, to get the long-term unemployed back to work. The practice is proving tricky for a number of reasons. One is that lines of accountability are hard to police in a vast inter-locking network of different providers operating in different regions. This flaw has been exposed in the case of Jubilee crowd stewards allegedly being asked to sleep under London Bridge – and foregoing wages – in order to gain experience of crowd management. The chain of command from the DWP to a prime provider to a secondary provider to an actual employer means it is hard to say what the case actually expresses about the policy. Whose bad decision was it and to what degree does that express a systemic flaw? 

The same issue is raised by recent allegations of fraud at A4e, once a major beneficiary of DWP contracts, although it must be pointed out that the accusations relate to bits of A4e’s past practice and not its Work Programme activity. The point is that a private company, doing work on behalf of the government, is accused of wrongdoing. Had the whole thing been run in-house at the DWP, a minister would be called to answer for it. Now there is a danger of accountability leaking through the gaps.

But by far the biggest problem is the labour market itself. As I have noted before, the Work Programme was designed, and its funding arrangements set, with an eye to fiscal and labour market forecasts from the Office for Budget Responsibility (OBR). These forecasts have all subsequently been revised in a more pessimistic direction. Even before the revisions, many observers and industry insiders expressed concern that the funding model was unrealistic.

An important reservation was that small providers – the ones most likely to actually innovate and know the job market terrain in which they work – could never manage with the kind of cash flow constraints that the DWP insisted on when negotiating contracts. So a handful of giant companies got the prime contracting work and then sub-contracted out the actual business of placing people in jobs – and the financial risk -  to smaller players, often charities. At least one charity has pulled out. Others are rumoured to be on the brink.

A good account of the flaws in the model, based on past records of non-state providers meeting their targets for getting people into work, was published by the Social Market Foundation in August 2011.

What is becoming increasingly clear is that the Work Programme was conceived at a time when the main problem with unemployment was thought to be difficulty in matching people to jobs, training them and motivating them to take what was on offer. Those are still issues in some areas and some cases, but much deeper structural problems with the labour market are now apparent. So too are regional variations that mean there simply aren’t vacancies to be filled.

But the feature of the labour market that seems to be causing most problems for the image of the government policy is the decline in decently-paid low- and semi-skilled jobs alongside a vast expansion of unpaid work in the guise of “experience” and “internships”. This too was the defining feature of the Jubilee steward story. For the employer (and presumably the Work Programme provider) it seemed quite reasonable to offer unpaid work as a precursor to paid work. This is well-established in the jargon as one of the “pathways” back to labour market participation. But that concept relies on the assumption that people need coaxing off a cosy life on benefits. Many are far more preoccupied by the urgent need for wages.

This too was the problem with the government-sponsored work experience scheme (not the same as the Work Programme) that caused a minor scandal last year. Companies were accused of employing “slave labour” – welfare-claimants who were given to understand that their benefits would be docked if they didn’t show up. The DWP vehemently denied that such a sanction was official policy.

Defenders of the policy argued then too that “work experience” was an essential staging post on the route back to actual work. Opponents pointed out (amid more lurid claims) that the scheme was essentially providing a taxpayer subsidy for the companies that would otherwise have had to recruit people to stack shelves etc. and pay them. The government’s welfare-to-work policies are meant to match people with actual vacancies, but in the absence of demand from employers they are creating perverse incentives for people to work without wages.

It is important to disentangle two things. On one hand, there is the original ethos of a policy that emerged from many years of frustration with government’s constant inability to find work for people who were claiming benefits even when the economy was growing and, by many measures, there were jobs to be had. Second, there is long-term downward pressure on wages at the bottom end of the labour market, compounded by stagnation, a global shortage of demand, low investment, public sector cuts and only modest private sector job creation. In such conditions, the best welfare-to-work policy conceivable would run into difficulty. No wonder the Work Programme, very far from perfect, is in trouble. But even if it fails in a downturn, something very much like it will still end up being re-invented for the recovery.

Secretary of State for Work and Pensions Iain Duncan Smith arrives for a Cabinet meeting at 10 Downing Street. Photograph: Getty Images.

Rafael Behr is political columnist at the Guardian and former political editor of the New Statesman

Photo: Getty Images
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British mental health is in crisis

The headlines about "parity of esteem" between mental and physical health remain just that, warns Benedict Cooper. 

I don’t need to look very far to find the little black marks on this government’s mental health record. Just down the road, in fact. A short bus journey away from my flat in Nottingham is the Queens Medical Centre, once the largest hospital in Europe, now an embattled giant.

Not only has the QMC’s formerly world-renowned dermatology service been reduced to a nub since private provider Circle took over – but that’s for another day – it has lost two whole mental health wards in the past year. Add this to the closure of two more wards on the other side of town at the City Hospital, the closure of the Enright Close rehabilitation centre in Newark, plus two more centres proposed for closure in the imminent future, and you’re left with a city already with half as many inpatient mental health beds as it had a year ago and some very concerned citizens.

Not that Nottingham is alone - anything but. Over 2,100 mental health beds had been closed in England between April 2011 and last summer. Everywhere you go there are wards being shuttered; patients are being forced to travel hundreds of miles to get treatment in wards often well over-capacity, incidents of violence against mental health workers is increasing, police officers are becoming de facto frontline mental health crisis teams, and cuts to community services’ budgets are piling the pressure on sufferers and staff alike.

It’s particularly twisted when you think back to solemn promises from on high to work towards “parity of esteem” for mental health – i.e. that it should be held in equal regard as, say, cancer in terms of seriousness and resources. But that’s becoming one of those useful hollow axioms somehow totally disconnected from reality.

NHS England boss Simon Stevens hails the plan of “injecting purchasing power into mental health services to support the move to parity of esteem”; Jeremy Hunt believes “nothing less than true parity of esteem must be our goal”; and in the House of Commons nearly 18 months ago David Cameron went as far as to say “In terms of whether mental health should have parity of esteem with other forms of health care, yes it should, and we have legislated to make that the case”. 

Odd then, that the president of the British Association of Counselling & Psychotherapy (BACP), Dr Michael Shooter, unveiling a major report, “Psychological therapies and parity of esteem: from commitment to reality” nine months later, should say that the gulf between mental and physical health treatment “must be urgently addressed”.  Could there be some disparity at work, between medical reality and government healthtalk?

One of the rhetorical justifications for closures is the fact that surveys show patients preferring to be treated at home, and that with proper early intervention pressure can be reduced on hospital beds. But with overall bed occupancy rates at their highest ever level and the average occupancy in acute admissions wards at 104 per cent - the RCP’s recommended rate is 85 per cent - somehow these ideas don’t seem as important as straight funding and capacity arguments.

Not to say the home-treatment, early-intervention arguments aren’t valid. Integrated community and hospital care has long been the goal, not least in mental health with its multifarious fragments. Indeed, former senior policy advisor at the Department of Health and founder of the Centre for Applied Research and Evaluation International Foundation (Careif) Dr Albert Persaud tells me as early as 2000 there were policies in place for bringing together the various crisis, home, hospital and community services, but much of that work is now unravelling.

“We were on the right path,” he says. “These are people with complex problems who need complex treatment and there were policies for what this should look like. We were creating a movement in mental health which was going to become as powerful as in cancer. We should be building on that now, not looking at what’s been cut”.

But looking at cuts is an unavoidable fact of life in 2015. After a peak of funding for Child and Adolescent Mental Health Service (CAMHS) in 2010, spending fell in real terms by £50 million in the first three years of the Coalition. And in July this year ITV News and children’s mental health charity YoungMinds revealed a total funding cut of £85 million from trusts’ and local authorities’ mental health budgets for children and teenagers since 2010 - a drop of £35 million last year alone. Is it just me, or given all this, and with 75 per cent of the trusts surveyed revealing they had frozen or cut their mental health budgets between 2013-14 and 2014-15, does Stevens’ talk of purchasing “power” sound like a bit of a sick joke?

Not least when you look at figures uncovered by Labour over the weekend, which show the trend is continuing in all areas of mental health. Responses from 130 CCGs revealed a fall in the average proportion of total budgets allocated to mental health, from 11 per cent last year to 10 per cent in 2015/16. Which might not sound a lot in austerity era Britain, but Dr Persaud says this is a major blow after five years of squeezed budgets. “A change of 1 per cent in mental health is big money,” he says. “We’re into the realms of having less staff and having whole services removed. The more you cut and the longer you cut for, the impact is that it will cost more to reinstate these services”.

Mohsin Khan, trainee psychiatrist and founding member of pressure group NHS Survival, says the disparity in funding is now of critical importance. He says: “As a psychiatrist, I've seen the pressures we face, for instance bed pressures or longer waits for children to be seen in clinic. 92 per cent of people with physical health problems receive the care they need - compared to only 36 per cent of those with mental health problems. Yet there are more people with mental health problems than with heart problems”.

The funding picture in NHS trusts is alarming enough. But it sits in yet a wider context: the drastic belt-tightening local authorities and by extension, community mental health services have endured and will continue to endure. And this certainly cannot be ignored: in its interim report this July, the Commission on acute adult psychiatric care in England cited cuts to community services and discharge delays as the number one debilitating factor in finding beds for mental health patients.

And last but not least, there’s the role of the DWP. First there’s what the Wellcome Trust describes as “humiliating and pointless” - and I’ll add, draconian - psychological conditioning on jobseekers, championed by Iain Duncan Smith, which Wellcome Trusts says far from helping people back to work in fact perpetuate “notions of psychological failure”. Not only have vulnerable people been humiliated into proving their mental health conditions in order to draw benefits, figures released earlier in the year, featured in a Radio 4 File on Four special, show that in the first quarter of 2014 out of 15,955 people sanctioned by the DWP, 9,851 had mental health problems – more than 100 a day. And the mental distress attached to the latest proposals - for a woman who has been raped to then potentially have to prove it at a Jobcentre - is almost too sinister to contemplate.

Precarious times to be mentally ill. I found a post on care feedback site Patient Opinion when I was researching this article, by the daughter of a man being moved on from a Mental Health Services for Older People (MHSOP) centre set for closure, who had no idea what was happening next. Under the ‘Initial feelings’ section she had clicked ‘angry, anxious, disappointed, isolated, let down and worried’. The usual reasons were given for the confusion. “Patients and carers tell us that they would prefer to stay at home rather than come into hospital”, the responder said at one point. After four months of this it fizzled out and the daughter, presumably, gave up. But her final post said it all.

“There is no future for my dad just a slow decline before our eyes. We are without doubt powerless – there is no closure just grief”.

Benedict Cooper is a freelance journalist who covers medical politics and the NHS. He tweets @Ben_JS_Cooper.