Incapacity benefit, employment transitions, and health : evidence from longitudinal data and a qualitative study

Background: UK welfare reform endeavours to reduce out-of-work health-related benefit receipt and support people into employment. Such reforms assume that work is good for health and that targeting welfare-to-work interventions at individuals will result in moves from benefit receipt to employment. The research in this thesis tackles two questions associated with UK welfare reforms: (1) Is work always good for health? And, (2) Is the focus on motivating individual Incapacity Benefit (IB) and Employment and Support Allowance (ESA) recipients appropriate, or are there barriers to return to work that this approach cannot address? Methods: Three approaches were taken to address the aims: 1) Longitudinal analysis, using Generalised Estimating Equations, of the West of Scotland Twenty-07 Study (Twenty-07), to explore transitions from worklessness to employment. The analyses looked at both employment and health outcomes (self-rated and anxiety or depression) and took account of the psychosocial quality of the jobs obtained. 2) A systematic review of qualitative studies that explored the barriers and/or facilitators to employment from the perspective of people out of work because of health conditions or disabilities. A qualitative synthesis, using meta-ethnography, of the included studies was conducted. 3) A primary study utilising in-depth interviews with IB and ESA recipients, General Practitioners (GPs), and Employment Advisors (EAs) in Glasgow, to gain more understanding about barriers and facilitators to work and to fill the gaps identified in the qualitative synthesis. The interviews were analysed using Framework Analysis methods. Findings: Findings from Twenty-07 data showed that only 6.6% of those out of work because of ill health returned to work within the follow-up period. After a transition from worklessness to employment those in low-quality jobs had higher odds of poor health than those who moved to high-quality jobs, even after taking account of prior health. Those who remained workless had higher or similar odds of poor health as those who had moved to low-quality jobs. Nine studies were synthesised in the systematic review. Participants in the studies identified similar barriers and/or facilitators to return to work. Barriers and facilitators were related to health, workplace factors, the need to change job, financial issues, life stage and social circumstance, support, and self-construct. Synthesis and interpretation of the studies led to themes that were then further explored. These themes were: the complex pathway of return to work; competing participant and author narratives, and a difficulty of interpretation; the distinction between expected and experienced barriers to work; differences in barriers and facilitators by participant characteristics; job quality; and work-role centrality, adaptation, and financial risk. Seventeen IB or ESA recipients, six GPs, and six EAs participated in the qualitative study. Their barriers and facilitators to work confirmed the findings of the systematic review. All IB/ESA recipients had multiple and interacting barriers that were not limited to their motivation but also related to wider labour-market and social-context issues. Those with complex social situations and mental health conditions had lower expectation that they would successfully return to work. All participant groups were concerned that the policies of the welfare system did not match up with the labour-market or the social context. Conclusions: A very low proportion of those out of work because of ill health transitioned into employment. This is concerning because current policy is to reduce the number of people receiving IB and ESA. The research showed that there is a significant challenge to support this group into employment and that policies focusing on motivating individuals may miss important barriers to return to work. There appear to be health benefits from return to work; however, job quality is important, and the potential for health improvement is limited if the job is of poor quality. Supporting people into work has the potential to improve health, but more effort is required to determine how to improve support and target where it is most needed. Further research is necessary to explore the results of the current welfare reform i.e. whether IB/ESA recipients move into work, what helps them do so, and whether they experience a change in health.