PIP, Parity, and the Past: why history matters
Kate McAllister | 6 February 2019
◇ Modern History | British History | Disability History | Medical Humanities
Few would deny that living with a mental health condition today often means living with stigma, limited support, or access to services. It has also become recognized that these issues do not affect people living with a physical health condition in the same way, thus leading to calls for ‘parity of esteem’ from charities such as Mind. 
Parity of esteem is best understood as valuing mental health equally with physical health, and in 2015 a government taskforce was created to achieve this. 
Nonetheless, disparity was recently brought into sharp focus by researchers at the University of York, who revealed significant differences in the allocation of Personal Independence Payment (PIP) to people who have a mental health condition, in comparison to people living with physical health conditions such as diabetes.
PIP was introduced as part of the 2012 Welfare Reform Act, and supports people aged 16 to 64 who are living with long term health conditions or disability. 
York researchers cited the “informal observation” of appearance and body language in order to make decisions regarding eligibility as a potential cause of this disparity.
Nonetheless, history provides useful insight when attempting to understand how, rather than just why, such disparity between the mental and the physical may emerge in welfare contexts.
This is exemplified by the work of Rhodri Hayward, who traced the emergence and uses of the concept of the ‘unconscious’ in early twentieth century British primary healthcare. 
In this comprehensive book, Hayward’s focus on how the unconscious facilitated the interrogation of insurance or compensation claims in the wake of early twentieth-century welfare legislation, is particularly compelling.
Hayward defined the unconscious as the belief that there is “some sort of inner agent which records our experience and organizes its embodiment” which is beyond our control. 
In the early twentieth century, the passage of the Workmen’s Compensation Act (1897, 1900, and 1906), and the National Health Insurance Act (1911) offered a new scheme of sick pay and remuneration for the working population of Britain. These welfare policies set in motion significant changes in primary care. In the doctor/patient relationship the interests of the latter changed, as they became a claimant seeking financial compensation or insurance, not just medical treatment.
This legislation thus also stimulated a wave of insurance and compensation claims from the working population. Contemporaries lamented the economic and social implications of this increase, highlighting that a situation had been created where “any experience of sickness was bound up with the possibility of unearned reward.” 
The unconscious was vital to navigating and disciplining these complexities, and identifying malingerers. Crucially, the use of this concept allowed claims to be assessed without creating an oppositional relationship between the doctor and the claimant.
Moreover, contemporary medical professionals identified the group of “unconscious malingerers” whose “symptoms may be founded on fact, but are mostly imaginary.”  Such claimants continued to seek compensation long since their “real physical disabilities” had disappeared. 
Technological developments in electrophysiology facilitated the interrogation of a claim, as by detecting electrical currents produced by the heart, the ‘galvanometer’ was believed to reveal the “unspoken attractions and intentions of an investigative subject.”  In becoming quantifiable and measurable, the acceptance and use of the unconscious were solidified.
Hayward also sheds light on the place of the unconscious today, as he suggested that we may now have entered an “age of cosmetic psychiatry”, where psychological health is understood as within our control. 
In this new age, we are encouraged to shape our identities through an eclectic package of pharmaceutical and therapeutic treatments such as anti-depressants or mindfulness courses.
If we accept this shift, it is important to question what psychological concepts have or will replace those such as the ‘unconscious’ as a means of understanding the health, characters, and lives of others and ourselves. It is moreover useful to consider how these concepts may operate, discipline, or discriminate in a welfare context, such as a PIP assessment.
In his work, Hayward demonstrated how the unconscious shaped insurance and compensation administration. Married with new language and developing electrophysiological technology, this concept supported the interrogation, investigation, and assessment of claimants, and most importantly, the detection of malingerers. The acceptance and meaning of the unconscious was in turn shaped and reinforced by the language and practice which grew up around it.
By analyzing the use of this concept, Hayward demonstrated that it is possible to grasp why some people were granted insurance or compensation, and why others were not. His contentions and approach are therefore useful when trying to understand the current enduring and damaging disparity between mental and physical health, which has been highlighted by researchers and evidenced in PIP assessments.
Hayward’s work provides us with a useful template to analyse how, and therefore to understand why, people with mental health conditions are currently losing their welfare entitlement to PIP. His contentions should force us to question how current psychological concepts continue to facilitate and shape the decision-making process and outcome for PIP claimants, and whether these concepts have a role to play in disparity.
There are no simple answers to why parity of esteem continues to be so elusive in practice. This blog hopes, however, to have presented some useful tools to begin to ask the right questions.
Kate McAllister is a first year PhD student at the University of Sheffield’s Department of History. Her research is funded by the Wellcome Trust, and aims to contextualise the current parity of esteem agenda, demonstrating that although this concept has shaped policy for over a century, implementing it in practice has recurrently failed. To navigate the complexities of this issue, her thesis focuses on the outbreak of Epidemic Encephalitis in Sheffield during the 1920s and 1930s.
 Rhodri Hayward, The Transformation of the Psyche in British Primary Care, 1870–1970, (London: 2014)
 Hayward, Transformation of the Psyche, xi
 Hayward, Transformation of the Psyche, p.37
 Hayward, The Transformation of the Psyche, p.36
 Hayward, Transformation of the Psyche, p.36
 Hayward, Transformation of the Psyche, p.42
 Hayward, Transformation of the Psyche, p.130