Health of the working age population
Authors: David Snashall
Journal: BMJ (2008)

On 17 March 2008, Dame Carol Black launched her review of the health of the United Kingdom’s working age population, “Working for a Healthier Tomorrow.”1 Importantly, the review was presented to the secretary of state for work and pensions as well as the secretary of state for health. Dame Carol’s position as national director for health and work straddles the two departments that, along with the Health and Safety Executive (sponsored by the Department of Work and Pensions), have been working together since 2005 on a health, work, and wellbeing agenda.2

The review was informed by a “call for evidence,” which produced more than 260 written responses from various organisations including occupational health organisations, patient groups, employers, local councils, trades unions, and even the “big lottery fund.”

The review is reminiscent of the report published by Dame Carol’s predecessor as president of the Royal College of Physicians, Sir Douglas Black, in 1980.3 That report, which the government of the day tried to suppress, examined inequalities in health. This new Black review examines a similar failure of health and social policy in a neglected section of the British population—people of working age.

Welfare payments cost £30bn (€38.6bn; $59.4bn) each year in people of working age, and incapacity benefits given to 2.5 million people make up 36% of this cost. Much of the descriptive part of the review covers incapacity to work as a result of ill health. Many people with health conditions or long term disabilities can work and want to work, but they are dissuaded from doing so by societal expectations and sometimes by overprotective doctors. The truism that work is good for you has only recently been evaluated in detail.4 Getting sick employees back to work as soon as possible is not just of economic benefit to the government—it is a positive health promoting measure for patients that all doctors should adopt.

So why has the problem not been sorted out before in a country with a National Health Service and a well developed benefits system? The review cites many reasons: in contrast to many European countries, occupational health services were not incorporated into the NHS at inception; there are often long delays in investigating non-serious but work limiting conditions (such as shoulder pain); back pain and mild to moderate mental health conditions are excessively medicalised and often wrongly attributed to work; the “sick note” system is an unaudited farce misused by doctors and patients alike; employment law in relation to ill health is complex; and benefit payments can provide perverse incentives to stay out of work.

So what solutions does the review provide? The main measure, unfortunately announced in isolation before the publication of the review, was that sick notes should be replaced by “fit notes.” This idea has proved unpopular with general practitioners, who see themselves primarily as patient advocates.

Comprehensive occupational health services are accessible to only 3% of the working population in the UK, so general practitioners are key to improving the medical management of people both in and out of work. The review recommends the mainstreaming of occupational health into the UK’s healthcare system. Rather than going for a full blown national service framework for health impairment in relation to work, Dame Carol prescribes a “case-managed multidisciplinary Fit-for-Work service based on the bio-psychosocial model which would ensure a prompt, holistic assessment of patient’s needs and provide them with an individualised action plan for achieving recovery.” This case management approach has face validity, but so far the results of trials have been mixed,5 and it is labour intensive and expensive. It will need to be run by highly trained and sensitive people, and it is vulnerable to being criticised by cynics who detect economic rather than health promoting imperatives. Electronic fit notes and a “fit for work” service are two of 10 practical recommendations that urgently need to be piloted.

Solutions are difficult because of entrenched social attitudes (which deride the sick note or benefits culture), and the UK has not utilised the skills of occupational health or rehabilitation professionals in the same positive way as some other countries, such as those in Scandinavia.

Dame Carol makes a good case for rejecting the status quo, and that money must be spent to save money. Her suggestions will require real investment—mainly government investment in making occupational health support available much more widely and the involvement of more people across a range of disciplines. Will the government, employers, and our patients trust one another and give these initiatives a chance? A consensus statement in the review (p 67) suggests that the healthcare community is ready to go.1