CSP PredictingPolicyPerformance

0010.1177/0261018318820173Critical Social PolicyBenstead research-article2018 Critical Social Policy Article Predicting policy performance: Can the Work and Health Programme work for chronically ill or disabled people? Stef Benstead Research Consultant, England Abstract Many developed countries consider that disability benefit receipt is too high and more disabled people should be in paid work. Employment pro- grammes designed to achieve this have tended towards less financial support and more requirement to engage in activity. But emphasis on social inclusion through paid work coupled with inadequate benefits and mandated activity can cause distress and worsened health. It is there- fore vital that politicians understand the likely impact of employment programmes before introducing them. In this article, a new framework based on five ‘Ds’ (diagnosis, destination, development, design and delivery) is used to analyse the UK’s Work and Health Programme. It is shown that the programme is likely to fail: it includes measures that do not work, and may cause harm, whilst ignoring measures that are known to work. Based on this, it is recommended that this programme be scrapped and the government start listening to disabled people. Key words disability, employment programme, evidence-based policy, incapacity, policy analysis Corresponding author: Stef Benstead, Research Consultant. Email: stef.benstead@cantab.net Critical Social Policy 1–20 © The Author(s) 2018 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0261018318820173 journals.sagepub.com/home/csp https://doi.org/10.1177/0261018318820173 2 C r i t i c a l S o c i a l P o l i c y 00(0) Introduction Many developed countries perceive sickness benefit receipt as excessively high and a “social and economic tragedy” (OECD, 2010). This is conceived as problematic on three fronts: for the individual, who cannot become a self- supporting adult; for the country, which risks developing a poor work ethic; and for the economy, which suffers through lost tax revenue and increased benefit payments (DWP and DH, 2016). Almost all OECD countries have, therefore, been implementing reforms that aim to increase the proportion of disabled people in work (OECD, 2010; EC, 2016). There has been a common shift to: a (nominal) focus on capa- bility rather than disability; cost reductions through stringent eligibility requirements, time limits on claims, and lower benefit levels; and increas- ing mandation to participate in employment programmes (Devetzi, 2011). Few countries invest significantly in either prevention or long-term support measures, with most focussing only on short-term, work-first approaches once sick leave has started (EC, 2016). It remains open to question whether the conceived-of problems are, in fact, problems. No person is ever truly independent of the state, and ‘depen- dence’ is a multi-faceted continuum rather than a discrete situation. Even high-net-worth individuals are dependent upon the infrastructure, stability, prosperity and labour force of the country in which they live or work. People unable to work do still participate in society through other means, not only through the vital social roles but also by acting as consumers and employers (Prideaux et al., 2009). We will see later that the UK has no reason to fear a work ethic problem. The UK government has not engaged with either of these contentions or economic arguments in favour of increased benefit spending, as it focusses on paid work as ‘the’ route to ‘independence’. At the same time, it is one of the worst performers in actually assisting disabled people to achieve its ideal (Barbier, 2001; OECD, 2003). Its latest employment scheme for disabled people in England and Wales, the Work and Health Programme (WHP), makes more demands on disabled benefit recipients, whilst offering noth- ing in the way of long-term employment or health support (Richardson and Benstead, 2017). Like many governments and programmes before, the WHP is touted as mitigating a cut to sickness benefits by getting more sick and disabled people into work (Osborne, 2015; Work and Pensions Committee (WPC), 2016). It is part of a trend of reduced benefit and increased requirements in the UK ever since the first true sickness benefit, Invalidity Benefit, was introduced in the UK in 1971. The current sickness benefit includes a ‘middle’ group of disabled people, deemed unfit for work but fit for work-related activity. It is these people who had their benefit cut from £102.15/week to £73.10/week Benstead 3 from April 2017, barely above destitution (Fitzpatrick et al., 2017), and to whom (in England and Wales) the WHP applies. If the UK is to mitigate these cuts, it is vital that any employment pro- gramme it provides is successful in getting more disabled people into good work more quickly than they would have done without the programme. This would require an employment programme of substantially better quality and efficacy than any preceding programmes (OECD, 2003; Roulstone, 2014). Is the Work and Health Programme it? A framework for analysing policy The Work and Health Programme (WHP) started in London and Manchester towards the end of November 2017, but has yet to be rolled out nationwide. This means that the policy cannot be analysed based on its performance. We cannot be 100% sure in advance what effect a policy will have, but that does not mean that we cannot anticipate those failures which are likely or possible. Previous analyses of implemented policy show that understanding the way in which a policy was developed and implemented is key to understanding why a particular policy has failed (Hallsworth and Rutter, 2011; Rutter et  al., 2012; King and Crewe, 2013; Schuck, 2014). It should therefore be possible to analyse a policy before full implementation. Table 1 shows four frameworks for analysing policy such as the WHP, taken from the aforementioned four reports. Hallsworth and Rutter (2011) recommend seven fundamentals for good policy making, based on previous analysis of failed policy (Hallsworth et al., 2011). Rutter et al. (2012) suggest seven lessons from successful policies, though they caution that “[t]his does not represent a checklist for policy success” (2012: 17) and any attempt to create one would be unwise. Schuck (2014) suggests six necessary attributes for policy success, and ten sources of policy failure, which include the converses to the attributes for success. King and Crewe (2013) suggest five human errors and seven system failures that are com- mon to failed policies. Whilst each framework shares common features with the others, each also contains gaps relative to the others. For example, only Hallsworth and Rutter’s (2011) ‘fundamentals’ includes the policy goal, but they have not included negative behavioural responses as a specific risk (Schuck, 2014; Gibb, 2015), and nor do they suggest questioning the legitimacy of a given policy goal. King and Crewe (2013) present their framework negatively – what is done wrong – whilst the others predominantly present theirs positively – what should be done. All four frameworks shown do, however, include the impor- tance of quality evidence and a good delivery, including clear oversight and a system for feedback and improvement.  4 Table 1.  A new 5-D framework for policy analysis and its fit with four previous frameworks. Hallsworth and Rutter (2011) Rutter et al. (2012) Schuck (2014) King and Crewe (2013) Diagnosis Underlying ideas behind the policy Understands the past Evidence should be accurate, unbiased Prejudice, overbearing ideological are rigorously evidenced and learns from failure and up-to-date; not inadequate, costly or dominance and insufficient pragmatism out-of-date Evidence is high-quality and up-to- Rigorous in analysis Collective irrationality, heuristic biases or Asymmetries of expertise date and use of evidence bounded rationality in decision making   Lack of deliberative, evidence-based policy making   Actively or passively ignoring evidence Destination Well defined and framed policy goals   Good fit between specific policy goal   and higher-level goals Development Adequate external consultation with Policy process is Structural or endemic features of bureau- Cultural disconnect between policy those directly affected opened up cracy may cause problems makers and policy recipients Options were robustly appraised Take time and build Group-think and lack of devil’s advo- in scope for iteration cacy and adaptation Policy’s design has been rigorously Ministerial turnover and emphasis on tested and is sufficiently realistic short-term gains   Refusal to acknowledge problems Design Resilient to changes in external Able to result in desired behavioural High cost relative to benefit environment change Identified and weighed any risks Rational in terms of its selection of Mismanagement in terms of waste, C r i t i c a l S o c i a l P o l i c y 00(0) appropriate policy instruments or means fraud and abuse Table 1. (Continued) Hallsworth and Rutter (2011) Rutter et al. (2012) Schuck (2014) King and Crewe (2013) Benstead Cost-effective Perverse and unwanted effects such as   moral hazard and adverse selection   Minimise waste, fraud and abuse     The power of market forces to overcome,   go round or otherwise circumvent policy or intervention intentions   Limits to law and legislation   Delivery Responsibility for oversight and Recognise the impor- Adaptable to changing or dynamic envi- Disconnect between design and imple- delivery is clearly articulated and tance of individual ronment mentation understood leadership and strong personal relationships Feasible plan for feedback and Create new institu- Credible to private actors, e.g. believe   evaluation tions to overcome that government or policy makers will policy inertia commit to sustaining a policy   Build a wider con- Implementation failures, e.g. inconsistent Led by the news cycle stituency of support perspectives, multiple decision points, delays   Little initiation, implementation or monitoring of policy by Cabinet-level ministers   Lack of parliamentary or democratic accountability 5 6 C r i t i c a l S o c i a l P o l i c y 00(0) The issues raised in the frameworks have been grouped into five sub- topics, based on the overlap between frameworks and the features of policy development. The result was a natural breakdown into five areas: the initial problem that policy makers believe needs addressing (diagnosis); the outcome they want to achieve (destination); the process of creating new policy (devel- opment); the actual design of the final policy (design); and the way in which the policy is implemented (delivery). Using this framework of five ‘Ds’ could help policy makers and academ- ics to analyse policy before it is implemented as well as after. In this article, I use this framework to analyse the WHP and predict its likely performance. The 5-D framework for policy analysis Diagnosis Every policy starts from identifying a problem that needs to be fixed. If the cause of that problem, or even the problem itself, is misidentified, then policy based on it is likely to fail: one would not prescribe antibiotics for influenza, or successfully treat a Crohn’s sufferer for anorexia. Identifying the real issue depends upon robust, up-to-date and extensive data (Hallsworth and Rutter, 2011; Rutter et al., 2012; Schuck, 2014). We have already seen that many countries are trying to reduce their sick- ness benefit caseloads. Underpinning this seems to be a widespread belief that current sickness benefit caseloads are not merely high, but too high (OECD, 2010). It is assumed that population health is improving (OECD, 2010), or at least not deteriorating at a rate adequate to explain the increase in sick- ness benefits (Beatty et al., 2000; Beatty and Fothergill, 2004). This belief is aided by awareness of the rising life and disability-free life expectancy (Jagger, 2015), and a reduction in the most injury-prone industries such as coal min- ing and quarrying (McKnight et al., 2001). The diagnosis therefore made by the UK’s Department for Work and Pensions (DWP) and Department of Health (DH) is that many sick and disabled people are unnecessarily and inappropriately out of work (DWP and DH, 2016, 2017). Some may have fallen into a ‘sick role’, in which they retain the habits and attitudes of a sick person despite hav- ing (largely) recovered (Waddell and Aylward, 2009). Others may have inappropriately believed their doctors, carers and/or benefits assessment which told them that they could not work (DWP and DH, 2016). And the relative generosity of sickness benefits may encourage people to try to get accepted on to what they perceive as an easier life (DWP, 2015). The problem therefore is not illness or disability, but wrong attitudes, behav- iours and illness beliefs. Benstead 7 Is this diagnosis correct?  The research cited by the DWP and DH as evidence of wrong attitudes is itself weak. One piece is an Opinium survey (Hall, 2013), which makes no direct link between external perceptions and the likelihood of work. Three are papers on lower back pain by McCluskey et  al. (2011, 2014, 2015). This small study, of ten white and mostly male manual labour- ers, lacks generalisability. Furthermore, the contention that labourers derive their view on their work capacity from what their partners think is not sup- ported. Instead, the papers show that what their partners think is derived from the severity of the labourer’s pain. Nor are sick and disabled people being misled by their GPs into believ- ing that they cannot or should not work. GPs are well aware of the positive effects of paid work (Money et al., 2010; Welsh et al., 2012). The difference is that GPs also recognise that work can be bad for people, and are able to identify this and use sick notes accordingly as a therapeutic tool (MacDonald et al., 2012). The DWP and DH do not mention this. The DWP and DH have ignored evidence that people on sickness benefits are largely not capable of work. Repeated research, even amongst researchers who champion the idea of illness as ‘hidden unemployment’, has found that the predominant factor keeping sick or disabled people from work is their work- limiting illness or disability, which is incompatible with sustained, reliable work (Berthoud, 1998; Stafford, 2007; Beatty and Fothergill, 2009; Becker et al., 2010). Even where sick or disabled people have been assessed as fit for work, they typically still need multiple adaptations if work is to be viable (DWP, 2013). Many people told they are fit for work do not make it into work (Ashworth et  al., 2001), with employment support providers reporting that they are being sent people who are demonstrably not capable of work (WPC, 2013). Allegedly less arduous ‘work-related activity’ can make sick people’s health worse (Hale, 2014) and conditionality programmes can make even healthy people sick through mental distress (Patrick, 2017; Raffass, 2017). The DWP and DH have ignored evidence that attending work whilst ill makes illness worse (Ashby and Mahdon, 2010), that work can make people ill (Baumberg, 2014; Chandola and Zhang, 2018), and that leaving work can result in health improving (Ding et al., 2016). Whilst the DWP and DH cite Waddell and Burton (2006) as showing that work is good for health, these authors suggest that 5–10% of the working age population, or 2–4 million, may be too sick or disabled to work (sickness benefit receipt, at 2.5 million, is towards the lower end of this estimate). Marmot (2010) concluded that there are many ‘toxic jobs’ in the UK which make people ill, and these ‘toxic jobs’ result in worse health than remaining unemployed (Butterworth et al., 2011; Chandola and Zhang, 2018). Bad jobs may have contributed to the rise in work-related disability, especially in the UK (Baumberg, 2014). At a deeper level, the assumption that being out of employment is a prob- lem is itself problematic. People are, and always have been, more than just 8 C r i t i c a l S o c i a l P o l i c y 00(0) producers; they are consumers, employers, family, friends and community members (Prideaux et al., 2009). And everyone, to some extent, depends upon the state if only for the stability in which to live and work successfully. The dichotomy of unemployed, dependent people who are problems versus inde- pendent, gainfully employed people who are contributors does not hold up. Nor is there a poor work ethic. Unemployed people including the sick and disabled retain strong commitments to gainful employment (Garthwaite, 2012). There are no differences in attitudes between those who do or do not move into work (Kemp and Davidson, 2010). The majority of people recog- nise work as a positive force that brings dignity, self-worth and fulfilment (de Wolfe, 2012; Kirsh et al., 2012). This strength of attachment to the labour market remains even when people’s experience of work is that it is insecure, high strain and low pay (Shildrick et al., 2012a, 2012b; Patrick, 2017). The DWP and DH have therefore made the wrong diagnosis. Sickness benefit recipients are not unemployed because of poor attitudes or behaviours; they are unemployed because of work-limiting disability. Destination Following diagnosis, policy makers have to decide upon the destination that they want to reach. In the UK, the government believes that sick and disabled people being out of work is a problem (DWP and DH, 2016). The desired goal, therefore, is to get these people into work. This has been concretised as one million more sick and disabled people in work by 2027 (DWP and DH, 2017). As discussed under ‘Diagnosis’, the problem that the DWP and DH have identified is not the right one. The desired destination is therefore also wrong. The DWP and DH say that work “is the best route to raising the liv- ing standards of disabled people and people with a long-term health con- dition and moving them out of poverty”. In fact work is increasingly not any, let alone the best, route out of poverty (Shildrick et al., 2012b; Hurrell, 2013). Bad work is harmful for most people (Marmot, 2010; Butterworth et al., 2011; Chandola and Zhang, 2018), and good work can be harmful for people who are ill (Ashby and Mahdon, 2010), as we have already discussed. Therefore, neither bad jobs generally nor jobs at all for those who are ill are the right solution to poverty, unemployment and social exclusion. The goal of lifting people out of poverty and assisting everyone to par- ticipate in and contribute to society is right, but it is not achieved solely by attempts to increase the participation of disabled people in gainful employ- ment. Whilst those who can and wish to work should be given all the nec- essary support to do so, including decent jobs to go to, there will always be people unable to participate in gainful employment, and these people should not be neglected by government (Abberley, 1999). The persistent Benstead 9 ineffectiveness of a range of approaches to getting disabled people into employment should show us two things: that there are many disabled peo- ple who cannot work; and that it is more than time that we challenged the economic-social paradigm that equates work and contribution with gainful employment (Abberley, 1999; Roulstone, 2014). Paid work is not the only contribution that people make, and therefore should not be integral to any definition, however implicit, of social member- ship (Abberley, 1999). Sick and disabled people should be enabled to par- ticipate in society through family, friend and community relationships; the multiplier effect of consumption; and the direct employment of carers and personal assistants (Prideaux et al., 2009; Roulstone, 2014). Because the DWP and DH do not take into account contributions and participation outside of paid work, the poor state of the UK labour market with its many bad jobs, and the nature and impact of chronic illness and disability in the UK that leaves many unable to work, they are unable to set an appropriate destination. Instead, they are imposing a narrow definition of contribution or participation upon people who broadly lack the health to work, and they fail to address the real issues of bad jobs and lack of support for participation more broadly. The appropriate goal would be to assist all sick and disabled people to participate meaningfully in society, including through non-work roles, and without threat of losing vital financial support or being required to engage in detrimental activity. Development As Table 1 shows, creating a new policy successfully requires establishing best practice based on previous research; consulting with experts and those involved at the delivery or receiving end of policy; and pilot studies to test and refine suggestions. The development process must be open to external, including critical, ideas to prevent group-think and cultural disconnect (King and Crewe, 2013). Particularly important is that the developers of the initial policy are not separated from those who will implement it (Hallsworth et al., 2011; Hallsworth and Rutter, 2011; King and Crewe, 2013). The DWP and DH’s use of evidence is weak. In their Green Paper, where they set out their plans and ideas, a search for ‘DWP’ shows that of the seven DWP research reports referenced in it, none are from the preceding govern- ment, and none are studies of employment support programmes (DWP and DH, 2016). One report did find that fewer than 3 in 4 Employment and Support Allowance (ESA) recipients thought work would be good for them or that they could work; that the support they wanted included employer incen- tives, healthcare, specialist employment support and modified hours, days and duties; and that two-thirds of those on the Work Programme found it unhelpful. However, the DWP and DH cited this report only to say that 52% 10 C r i t i c a l S o c i a l P o l i c y 00(0) of people in the ESA Support Group want to work, as if ‘want’ meant ‘could’; they failed to use it to inform their expectations of what sick and disabled people can do or of how best to support them (DWP and DH, 2016: 42). The pilot studies carried out by the DWP and DH did not build on pre- vious work, but essentially started from scratch. From previous DWP research reports, we already know the importance of using highly-skilled profession- als (Hills et al., 2001) with low caseloads (Hirst et al., 2005). We know that confidence-building measures have limited value, especially if progress stalls (Warrener et al., 2009); that sanctions can be counter-productive (Mitchell and Woodfield, 2008); and that it is important to provide space, sympathy and a non-pressured environment (Cotton et al., 2001; Davies et al., 2001). The recent pilot studies have merely re-confirmed what we already know, including: the importance of being in a voluntary environment (Lyne et al., 2017); the complexity and sensitivity of work capacity (Lyne et al., 2017); and the positive correlation between self-assessed work capacity and the severity of disability (Newton and Sainsbury, 2017). Sick and disabled people them- selves could have told the DWP that few people on ESA have lower back pain amenable to physiotherapy (Moran, 2017) or mild-moderate mental illness amenable to low-level Cognitive Behavioural Therapy (CBT) (Steadman and Thomas, 2015); and that the previous Work Programme drove people further away from work, not closer (Moran, 2017). Despite these pilot studies and existing literature, the DWP is pursuing approaches that are known not to help. Sanctions and conditionality have neg- ative effects on sick and disabled people, yet the DWP is expanding the use of mandatory engagement. The Improving Access to Psychological Therapies (IAPT) programme, which offers low-level CBT, is badly flawed and achieves limited success (Thomas, 2013; Booth, 2016). Yet the Working Well pro- gramme, which uses confidence-building and IAPT, and which does not yet show any success, is to be extended (GMCA, n.d.; DWP and DH, 2017). Work Coaches are not specialised even into mental versus physical conditions, but are generalist Jobcentre Plus staff, even though high levels of expertise and specialisation are vital. There are some instances where the DWP and DH are building positively on evidence and expert opinion. They are extending access to apprenticeships and internships for people with learning disabilities (DWP and DH, 2017: para. 60); looking into ways to help sick and disabled people to retrain and gain useful qualifications (para. 77); and linking Access to Work budgets to the individual, not their workplace (para. 89). These are all measures that sick and disabled people have been calling for. And in the DWP’s recent trials, providing access to training was one of the few concrete actions that Work Coaches took. The DWP and DH did consult on the WHP by inviting feedback to their initial proposals as laid out in their WHP Green Paper (DWP and DH, Benstead 11 2016). Unfortunately, the DWP, and indeed government as a whole (Easton, 2013; King and Crewe, 2013), has a poor track record of listening (Campbell et al., 2012) or intending to listen (Anon., 2013) to consultation responses. The Department of Health has a history of implementing policy with “reck- less haste” (Barrett, 2009) whilst some DWP policies, such as the Bedroom Tax, Mandatory Reconsideration and Universal Credit, were brought in with- out consultation. Policy makers report that outside expertise is not used well and that evaluations are often ignored (Hallsworth and Rutter, 2011). The DWP and DH did not perform a content analysis of the feedback they received, which means that we cannot tell how well they have listened. We do know that responses include recommending: the removal of sanc- tions, which has not been done; that Work Coaches be much better trained, which received only a negligible response; and that the government stop assuming that work is good for chronically ill people, to which the DWP and DH have reacted contrarily, saying now that work is “extremely ben- eficial to someone’s health and act[s] as an enabler to recovery” (DWP and DH, 2017: para. 56). The DWP claims to have undertaken extensive consultation with Dis- abled People’s Organisations (DPOs). However, when asked, the organisa- tions that had spoken with the DWP reported that the resulting policy did not reflect what had been discussed, rendering the consultation a consultation in name only (Pring, 2017). At the launch of the Green Paper, several major user-led DPOs were excluded, which only exacerbates concerns that the DWP is not listening (Pring, 2016). There is no indication that the DWP and DH have, in engineering par- lance, ‘tested’ the WHP ‘to failure’ (Richardson and Benstead, 2017). The DWP and DH should be asking themselves in what scenarios the policy might fail, how badly it could fail, and how many people it would affect. The prospect of chronically sick and disabled people being sanctioned into activity that makes their health worse, whilst living on an inadequate income, is very real (Hale, 2014; Low et al., 2015; Chandola and Zhang, 2018). The DWP and DH should have explicitly addressed this and explained how sick and disabled people will be protected from such harm. Design A good design is one that reliably results in the desired direction of travel with minimal harm, waste or fraud, and is more cost-effective than other oth- erwise suitable designs. It should be effective and bring positive social returns and, if appropriate, also financial returns. The real performance of the policy design can only be determined after its enactment, but the intended approach can be compared with previous policy design and research to predict whether it is likely to succeed and at what cost. 12 C r i t i c a l S o c i a l P o l i c y 00(0) It is not at all unusual in the developed world for countries to propose a reduction in benefits at the same time as an increase in employment pro- grammes (OECD, 2010; Heap, 2014). But the reality has been that employ- ment support is under-resourced and inadequate, and has little impact on employment levels (OECD, 2010). Common criticisms include: the tendency towards supported and sheltered employment (segregated employment or other programmes created specifically to employ disabled people, sometimes with government subsidies) over open employment; the poor match of work trials and work-related activity to the individual; the low ability of assessors to identify abilities and support needs; and the patchy and under-resourced nature of many support programmes (Geiger et al., 2018). In the UK, the lack of decent employment support has exacerbated the failure of ESA, making it a “higher-stakes and more traumatic assessment than it needs to be” (Baumberg et al., 2015: 15), as recipients are mandated to activity that does not help and frequently hinders their return to work (Hale, 2014; Dwyer et al., 2018). References to ‘rehabilitation’ and measures that focus on the individual show an underlying assumption that it is the individual that needs to change. This fits with wider focusses on supply- rather than demand-side factors, and a tendency to rely on the medical rather than social model of disability. Just as jobseekers are limited by a lack of jobs, so sick and disabled people are lim- ited by the wider environment and working conditions. Key barriers include inadequate public transport and a lack of reasonable adjustments or support from employers (Benstead, 2017). But the DWP and DH do not address these demand-side factors and socially-imposed disablement. The WHP is designed for people assessed as likely to be able to work in the next twelve months. It consists of a Health and Work Conversation prior to an assessment of a person’s capacity for work and support needs, fol- lowed after the assessment (for those assessed as eligible) by meetings with a Work Coach. The initial Health and Work Conversation is compulsory, and includes the drawing up of a Claimant Commitment. Claimants do not have to carry out any actions in the Claimant Commitment prior to their assessment. For those eligible for the programme, meetings with the Work Coach are adjusted to what the claimant is capable of. A ‘Personal Support Package’ is available, which consists of: 102 Small Employer Advisers to raise small employers’ awareness of the support available to them; 200 Community Part- ners with understanding of disability; 500 Disability Employment Advisers; and an additional 1000 places on a six-month Access to Work scheme for people with mental illness. The Work Coach has access to a Flexible Sup- port Fund which they can use at their discretion to buy in services that will assist their clients. The claimant and Work Coach may meet jointly with a healthcare professional, if this is felt to be beneficial to help the Work Coach understand what the claimant may reasonably be asked to do. Benstead 13 Scrutinising the reports written on the WHP trials (Lyne et al., 2017; Moran, 2017; Newton and Sainsbury, 2017), it becomes clear that the sup- port offered by Work Coaches was little more than talk and basic job-search help. Participants were ‘supported’, ‘encouraged’, ‘signposted’ or ‘persuaded’ to engage in social or work-related activity. Work Coaches were unable to directly train participants in basic skills, assess what work or work-related activity they might be able to do, assess and provide aids and adaptations, deliver counselling or physiotherapy, or liaise with employers to create or carve out suitable jobs. Yet these are the very skills that sick and disabled peo- ple need their employment support staff to have. Overall, the Work Coaches had little to no impact, with claimants who had secured work attributing this to themselves, their support networks or other organisations. The government is trialling, for people with mild-moderate mental ill- ness, a variant of the internationally-acclaimed Individual Placement and Support (IPS) model – even though few people on ESA have mild-moderate mental illness (Steadman and Thomas, 2015). The ‘true’ IPS model requires the combination of a secondary care mental health nurse with a highly-skilled and specialised employment support worker, and is the most successful employment support model that we have (Schneider et al., 2009; Heffernan and Pilkington, 2011). The employment support worker directly contacts employers to seek to create or open up jobs for people with mental illness. But the ‘mild’ version suggested by the government involves combining the Improving Access to Psychological Therapies (IAPT) service with Work Coach support. IAPT is a heavily-criticised programme (Barrett, 2009; Hall and Marzillier, 2009) that risks diverting resources away from higher-level or person-centred therapy (Watts, 2017). The Work Coaches are not highly- skilled experts. This cheap version of the IPS does not seem likely to offer the very things that made IPS successful. Indeed, the general ‘cheapness’ of the WHP is another reason to doubt its potential efficacy (Pickles et al., 2016). More generally, whilst activation programmes may, by a small number of percentage points, increase the speed at which jobseekers find work, this is counter-balanced by the temporary nature of the work that is found (Arni et al., 2013). Activation programmes disrupt job search (Griggs and Evans, 2010) and often result in people taking jobs below their skill level, and never climbing back up (van den Berg and Vikström, 2009). They cause finan- cial hardship and significant harm to mental health and well-being (Raffass, 2017). The imposition of conditions under the threat of sanctions is known to undermine, perhaps fatally, the relationship between the staff member and the individual (Nevile and Lohmann, 2011; Meershoek, 2012) and can harm the individual’s health (Hale, 2014). Even if paid work were an appropriate goal for one million of the UK’s 2.5 million sickness benefit recipients, it is unlikely that the WHP would positively contribute to this goal. 14 C r i t i c a l S o c i a l P o l i c y 00(0) Delivery For a successful delivery, the policy must be resilient and robust, to cope with unexpected faults or changes in environment, as well as with changes in political goals. Part of a good delivery is ensuring that policy designers and implementers worked together in creating the policy (Hallsworth et al., 2011; King and Crewe, 2013). Too often, designers do not know how to make a policy implementable, such that even good ideas can fail. But the WHP is not a good idea. Because the WHP is not yet widespread, there is little to say on its deliv- ery. However, the government’s failure to use research, past policy and con- sultation feedback to change the design of the WHP suggests that it will not substantively change the WHP based on poor delivery either. The apparent underpinning beliefs of the government suggest it will not readily change its mind on what is appropriate policy. Already, there are reports of people being required to search for blatantly absurd jobs, such as looking for a job of one hour per week, spread over five days (Halewood, 2017). The government’s fixation on the idea of paid employment as the solu- tion to a problem (bad attitudes) that is not as extensive as it believes, means delivery problems are likely to go unidentified or misinterpreted. Coupled with its poor track history of listening to sick and disabled people, it seems likely that the WHP will not be delivered well, and its flaws will continue. Conclusion The WHP is likely to fail. It is likely to cause harm to people with chronic illness or disability by requiring them to engage in activity of which they are not capable, under threat of (further) financial deprivation if they do not. It is unlikely that the policy will result in significant numbers of sick or disabled people moving into work; even the most successful programmes, such as fully-implemented IPS, only help one in four participants (Schnei- der et al., 2009). Sick and disabled people typically need multiple adapta- tions if they are to be able to work, including reduced and flexible hours, one-to-one support workers and physical adaptations to a workstation and workplace (DWP, 2013; Benstead, 2017). Yet the DWP and DH have not shown any sign that they are aware of these costs, let alone willingness to pay for them. The DWP and DH have misled themselves through their selective use of data. They have relied upon low-quality data, misinterpreted the data they did use, and failed to use a comprehensive range of evidence. By not paying attention to the evidence of harm caused by externally imposed activity, sanctions, poverty and lack of practical support, they risk causing significant Benstead 15 harm to sick and disabled people without achieving any good. The likeli- hood is that any sick or disabled person achieving work does so despite, not because of, the WHP. The 5-D approach to policy analysis as developed in this article has exposed the flaws in the WHP. The DWP and DH came to the wrong Diag- nosis and therefore set the wrong policy Destination. They failed to listen in the Development stage and were thus unable to address initial errors. Conse- quently, the Design is flawed and unlikely to help the minority of sick and disabled people who could work if given appropriate support. And finally, the DWP and DH’s poor use of evidence and lack of listening to experts does not bode well for the Delivery of this flawed policy. The DWP and DH should urgently listen to sick and disabled people regarding their needs and abilities, and move away from political assumptions regarding the value of work and the attitudes of people with chronic illness or disability. The WHP itself should be scrapped immediately and a new programme designed with sick and disabled people. The 5-D framework can be successfully used to analyse policy and may prove beneficial to policy makers wishing to ensure they make good policy. Funding This research received no specific grant from any funding agency in the pub- lic, commercial, or not-for-profit sectors. References Abberley P (1999) The Significance of Work for the Citizenship of Disabled People. Dublin: University College Dublin. 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Her work has been presented to MPs and discussed in the Houses of Parliament. Her main areas of work are on disability and the social security system. Ms Benstead is not affiliated with any university or other such research body. Most of her work is unpaid. Her book, Second Class Citizens, is due out in early 2019 and covers the history of the welfare state as it relates to sick and disabled people along with consideration of potential human rights violations since 2010.