In a radical move to cut the benefits bill, the government intends to force drug users into treatment and the long-term sick back to work. What will this mean for the health service, asks Charlotte Santry

Proposed welfare reforms have led to fears that the infirm could be thrust into unsuitable jobs to demonstrate the government's intolerance of "scroungers".

The premise of the Department for Work and Pensions' new green paper, No One Written Off: reforming welfare to reward responsibility, stems from William Beveridge's 1942 mission to tackle "idleness" and "ignorance". It argues that people who have traditionally lived off the state on the basis of being too ill or unskilled to work should be offered training and medical help and be stripped of their benefits if they refuse.

Restructuring benefits

Those who wish to claim the new employment and support allowance, which will replace incapacity benefit from October, will be assessed by a healthcare professional and placed in one of two categories. Those with the most severe disabilities will get a higher rate of benefit of£102.10 a week, and given the option of help to find employment. Those with less serious disabilities or illnesses will be placed in "work related activity groups", meaning they are expected to participate in employment programmes and carry out some form of work, the precise nature of which is yet to be decided. Drug addicts will face having their benefits stopped if they fail to attend treatment schemes.

While many have welcomed the attempt to expunge Britain's sick note culture, others fear the methods could be counter-productive and lead to a heavier burden on the NHS in the long term. Mental Health Foundation chief executive Andrew McCulloch highlights the difficulties many people with drug and alcohol addictions face in accessing services.

"Saying thousands of people will be forced to have treatment is disingenuous. We're not offering people the treatment - alcohol and drugs dependencies are the least treated of all mental health problems."

The problem is similar for people requiring physical rehabilitation, says NHS Alliance primary care lead David Jenner. "The ability of disabled people to return to work may be hampered by the lack of specific rehabilitation services," he says.

More pressure

Fraud rates for incapacity benefits are only around 0.5 per cent. People with mental health problems make up the biggest proportion of people on incapacity benefit but stigma makes it unlikely anyone would want to falsely claim they were mentally ill, charities say.

Mind chief executive Paul Farmer fears the tougher sanctions may pressure people to return to work before they are ready. "Facing this stark choice will undoubtedly cause them further distress and there's a high chance their condition could deteriorate in the long run," he says.

A new assessment of people's suitability for work will examine what people can do, instead of what they cannot. This is expected to raise the number of claimants able to leave the benefit system after three months by around 10 per cent.

The DWP paper states: "There was strong evidence that the old system… was identifying too many people as incapable of work.

"There was too much emphasis on whether they could still do the jobs they had previously done rather than looking at what jobs they could do in the future. This consigned far too many people to a life on benefits."

However, the threshold for claiming incapacity benefit is already felt by many to be too high.

Also, erroneous independent medical assessments have left thousands of needy claimants without state support: success rates for people who appeal decisions are high, at around 60 per cent.

Traumatic experiences

A 2006 Citizens Advice Bureau report was highly critical of private healthcare firm Atos Origin, which carries out many of the assessments. It claimed assessors were often insensitive, rushed and showed little understanding of mental health problems. Rethink head of campaigns Jane Harris shares these concerns and claims many of her members find the experience "traumatic". Atos Origin declined to comment.

Dr Jenner says it is unusual for GPs to receive any feedback from independent assessors regarding their patients, which can cause difficulties later on. But he stops short of suggesting family doctors should take over the role of deciding patients' eligibility for benefits.

"It's very difficult for a GP to be entirely objective because they build long-term relationships with patients and these depend on mutual trust, so I think it's right for GPs to give evidence but for the decision to be separated from them."

Suitable assessors

He admits that many doctors feel uncomfortable about giving a mental health diagnosis and the assessors should ideally be occupational therapists or trained psychologists.

After the initial medical assessment, those in the work-related activity groups will have their skills boosted through back-to-work support provided by the private, voluntary and public sectors.

Sainsbury Centre for Mental Health director of employment Bob Grove questions where the staff will come from, and whether there is a big enough supply of occupational therapists, psychologists and physiotherapists to feed the expanded services.

He also fears providers will "cherry pick" the easiest cases as they will be paid by results. "It's about creating the right incentives, not just about numbers of people but the distance of travel from where people started to where they finish," he says.

A DWP spokesman said people referred to providers have been unemployed for a year, meaning they are all "hard to help".

It will be important for these providers to work with employers to ensure people are supported in their roles. The Confederation of British Industry has already set the tone by warning businesses must not be "burdened" with staff with "limited work experience and other complex personal problems".

Legal help

The budget for Access to Work, which funds workplace adjustments for people with health conditions and disabilities, is being doubled, but Ms Harris says more is needed.

She is calling for changes to the Disability Discrimination Act to ban employers from asking people about their disability in job interviews. She also wants fewer restrictions on legal aid so more people are able to take claims to court. "We don't just need a stick for people on benefits, we need a stick for employers as well," she says.

Back to work programmes will be based on the existing Pathways to Work programme, which has been found to increase employment prospects by around a quarter. But Pathways' effectiveness for people with mental health problems was questioned in national health and work director Dame Carol Black's well received review of the health of Britain's working age population, published in March.

In its defence, the DWP says the£173m Improving Access to Psychological Therapies fund will improve support for people with mental health conditions. It says further funds will be made available to test the impact of employment support advisers who help people stay in work, find more suitable roles and return to work after sickness absence or from welfare benefits.

It is also building on this by setting out a national strategy for mental health and employment, for the first time co-ordinating a cross-government response to the challenges posed by people with mental health conditions.

Strategy steering group

A steering group of specialists, chaired by Dame Carol, will oversee the strategy, which will focus on how mental health provision can be better tailored and integrated to help people find, stay in or return to, work.

She says her priorities will be "pulling together all the thinking in terms of prevention, and the later stages, but also probably differentiating between mild stress-related disorders, which are what most people go out of work with, and more severe mental illnesses.

"A lot of these people want the opportunity to work even if it's not full time, so what is it that we need to do to enable that to happen?"

They will also discuss stigma and whether assessors have received mental health awareness training. She is pleased the government has chosen to pilot her recommendation for a service called Fit for Work, to reduce absence from work through ill-health. The group aims to report back to Parliament by next spring.

The fact that work around mental health is not being confined to one Whitehall department will delight campaigners who have long argued for more cross-governmental thinking. It may also mean the NHS is able to reap the financial benefits of any savings.

Higher spending

Martin Knapp, professor of health economics at King's College London's institute of psychiatry, thinks getting more unhealthy people off benefits and into work will inevitably involve a higher rate of spending by the NHS: community mental health services will need to be aligned with employment support programmes and public health funding will need to be sustained or increased to reduce sickness absence.

Professor Knapp argues this will be compensated for by savings to the overall economy through higher productivity and fewer state handouts, but warns "one of the key challenges is to shift money from other parts of the economy to the NHS". He sees Improving Access to Psychological Therapies as a good example of a health-based initiative, funded by the Treasury on the assumption it will save money for non-health departments. However, he says the government must do more.

A DWP consultation on the future of welfare ends on 22 October.

The cost of ill-health

  • Around 175 million working days a year are lost to illness.

  • Sickness absence and worklessness associated with working-age ill health are estimated to cost more than£100bn: more than the NHS annual budget.

  • Less than a quarter of people with mental health conditions and around half of all disabled people are in employment.

  • Mental health conditions are the biggest cause of absence from work.

  • Forty-one per cent of incapacity benefits claimants have mental and behavioural disorders, followed by musculoskeletal diseases at 17 per cent.

Sources: Dame Carol Black's review of the health of Britain's working-age population, Working for a Healthier Tomorrow; DWP green paper; DWP.