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Doctors are key to welfare reform

BMJ 2010; 341 doi: (Published 27 October 2010) Cite this as: BMJ 2010;341:c6029
  1. Clare Bambra, professor of public health policy, Wolfson Research Institute, Durham University
  1. clare.bambra{at}

The UK government’s comprehensive spending review has set out plans for unprecedented cuts to public sector funding. A particular focus has been on the Department for Work and Pensions’ budget and the £192bn (€215bn; $300bn) paid each year in welfare benefits.

Most attention has focused on incapacity related benefits (Incapacity Benefit, Disability Living Allowance, and Employment and Support Allowance), which account for £12.5bn of the welfare bill. The coalition government intends to move all the current 2.6 million recipients of incapacity related benefits onto other benefits (such as Jobseeker’s Allowance or Employment and Support Allowance). This will be done by using private sector agencies to reassess the health and fitness of all recipients over the next four years.

Those deemed “fit for work” will be transferred immediately to the lower paying Jobseeker’s Allowance (box). Those deemed to be too “incapacitated” for work will be placed on the Employment and Support Allowance, with a “support” premium and no conditions. Those considered “sick but able to work” will be placed on Employment and Support Allowance with a “work related activity” premium. Failure to engage in compulsory “work related activity” would result in loss of this premium and placement on the basic rate of the Employment and Support Allowance.

Weekly benefit rates in 2010

  • UK poverty line: £115

  • Incapacity Benefit: £91.40

  • Employment and Support Allowance (with support premium): £96.85

  • Employment and Support Allowance (with work related activity premium): £91.40

  • Employment and Support Allowance (basic): £65.45

  • Jobseeker’s Allowance: £65.45

  • Income Support: £65.45

Sources: Department for Work and Pensions; The Poverty Site (

The reforms also mean that those deemed “sick but able to work” will see their entitlement to Employment and Support Allowance limited to one year. After a year they will have no right to benefits (not even Jobseeker’s Allowance) and will therefore have to rely on family support, charities, or means tested assistance (Income Support). Of the 1.5 million claimants of Incapacity Benefit currently being reassessed, it is expected that more than half will be placed into this group.

These reforms have considerable implications for patients who receive Incapacity Benefit and potentially for their relations with general practitioners and other healthcare providers. The increase in surveillance, the uncertainty about benefit entitlement, and the stigma attached to being marked out by politicians and the press as “welfare scroungers” may well have negative effects on recipients’ self esteem and mental wellbeing. The reduced income they will receive is also likely to have a detrimental effect on their health and wellbeing. And recipients of Incapacity Benefit may be less willing to see their general practitioners and other health professionals because they may begin to perceive them as instruments of this renewed state surveillance.

Patients who claim incapacity related benefits often have complex and multiple chronic health conditions, and they have been out of the labour market and dependent on low value state benefits for a long time. They did not benefit from the economic boom, but the coalition government seems determined that they will bear the brunt of the bust.

Such welfare reforms may cut central government costs, but they are highly unlikely to be health promoting, and they are also unlikely to actually be effective in terms of getting people back into work. Our recession economy presents few suitable job vacancies (even if recipients “get on the bus,” as Iain Duncan-Smith suggested), and those that do exist are more likely to be filled by the newly unemployed than the long term sick. In addition, the welfare reforms are clearly not based on evidence of “what works” but on an ideological desire to shrink the state, combined with the view that those receiving Incapacity Benefit are work shy rather than chronically ill. This is in contrast to the research evidence showing that people receiving this benefit have multiple and complex long term illnesses and that the vast majority (up to 95% in a recent study in Easington, County Durham) cite ill health as their biggest barrier to gaining employment.

General practitioners and other primary healthcare providers therefore hold the key to reducing receipt of Incapacity Benefit by tackling the root cause: ill health. If welfare reform is actually about getting people into work (rather than just cutting expenditure, shrinking the state, and stigmatising the poor) then improving health is the most important first step in this process.

However, in all of the coalition’s talk of welfare reform, there has been very little mention of illness or of the potential role of health professionals in the process of return to work. In contrast, the research evidence indicates that a “health first” approach to welfare reform is the most effective. In 2009 the National Institute for Health and Clinical Excellence released evidence based guidance on managing long term sickness absence and incapacity for work (BMJ 2009;338:b1259, doi:10.1136/bmj.b1259). It recommended that integrated programmes, combining traditional vocational training approaches, financial support, and health support on an ongoing case management basis, should be commissioned to help Incapacity Benefit recipients enter or return to work. The institute considers these integrated approaches to be the most effective way to enhance the employability of people in long term receipt of Incapacity Benefit.

Such an approach is being piloted by County Durham and Darlington Primary Care Trust, which has commissioned Salus, an NHS based provider of occupational health services, to provide a “health first” case management approach for long term (three years or more) recipients of Incapacity Benefit. This pilot programme uses telephone and face to face case management programmes to identify individual health needs and any other related barriers to employment (such as debt or housing). The scheme is intended to complement mainstream services, with case managers signposting the patients to NHS, Department for Work and Pensions, and other health and welfare services. Patients are referred to the programme by other NHS services (such as the Alcohol Service) or their general practitioner, or they can refer themselves. The pilot is being evaluated by a multidisciplinary team of researchers based at the Wolfson Research Institute, Durham University.

Abandoning millions of people in deprived communities to a life on benefits is not desirable; but for welfare reform to be effective it needs to be considered outside the ideological box of spending cuts and to be based actively on the available research evidence. This evidence clearly shows that the healthcare sector—particularly general practitioners and case management techniques—holds the key to successful social inclusion and a healthy return to work. This is something that could be taken on board by those running the new Public Health Service; and involving general practitioners in welfare services could form part of the new system of general practitioner commissioning.


Cite this as: BMJ 2010;341:c6029