Work is not a ‘health’ outcome

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The Government is intending to “signpost the importance of employment as a health outcome in mandates, outcomes frameworks, and interactions with Clinical Commissioning Groups.”

A Department for Work and Pensions research document published back in 2011 – Routes onto Employment and Support Allowance – said that if people believed that work was good for them, they were less likely to claim or stay on disability benefits.

It was decided that people should be “encouraged” to believe that work was “good” for health. There is no empirical basis for the belief, and the purpose of encouraging it is simply to cut the numbers of disabled people claiming ESA by “encouraging” them into work. Some people’s work is undoubtedly a source of wellbeing and provides a sense of purpose. That is not the same thing as being “good for health”.

For a government to use data regarding opinion rather than empirical evidence to claim that work is “good” for health indicates a ruthless mercenary approach to fulfill their broader aim of dismantling social security and to uphold their ideological commitment to supply-side policy.

From the document: “The belief that work improves health also positively influenced work entry rates; as such, encouraging people in this belief may also play a role in promoting return to work.”

The aim of the research was to “examine the characteristics of ESA claimants and to explore their employment trajectories over a period of approximately 18 months in order to provide information about the flow of claimants onto and off ESA.”

The document also says: “Work entry rates were highest among claimants whose claim was closed or withdrawn suggesting that recovery from short-term health conditions is a key trigger to moving into employment among this group.”

“The highest employment entry rates were among people flowing onto ESA from non-manual occupations. In comparison, only nine per cent of people from non-work backgrounds who were allowed ESA had returned to work by the time of the follow-up survey. People least likely to have moved into employment were from non-work backgrounds with a fragmented longer-term work history. Avoiding long-term unemployment and inactivity, especially among younger age groups, should, therefore, be a policy priority. ”

“Given the importance of health status in influencing a return to work, measures to facilitate access to treatment, and prevent deterioration in health and the development of secondary conditions are likely to improve return to work rates”

The government made a political and a particularly partisan decision, rather than one that has any an evidence base, to promote the cost-cutting and unverified, irrational belief that work is a “health” outcome.

Furthermore, the research does conclude that health status itself is the greatest determinant in whether or not people return to work. That means that those not in work are not recovered and have longer term health problems that tend not to get better.

Work does not “cure” ill health. To mislead people in such a way is not only atrocious political expediency, it’s actually potentially downright harmful and dangerous.

The government’s Work and Health programme involves a plan to integrate health and employment services, aligning the outcome frameworks of health services, Improving Access To Psychological Therapies (IAPT), Jobcentre Plus and the Work programme.

2020health – Working Together is a report from 2012 that promotes the absurd notion of work as a health outcome. This is a central theme amongst the ideas that are driving the fit for work and the work and health and programme. Developing this idea further, Dame Carol Black and David Frost’s Health at Work – an independent review of sickness absence was aimed at reviewing ways of “reducing the cost of sickness to employers, ‘taxpayers’ and the economy.”

Seems that the central aim of the review wasn’t a genuine focus on sick and disabled people’s wellbeing and “health outcomes,” then. Black and Frost advocated changing sickness certification to further reduce the influence of GPs in “deciding entitlement to out-of-work sickness benefits.”

The subsequent “fit notes” that replaced GP sick notes (a semantic shift of Orwellian proportions) were designed to substantially limit the sick role and reduce recovery periods, and to “encourage” GPs to disclose what work-related tasks patients may still be able to perform. The idea that employers could provide reasonable adjustments that allowed people who are on sick leave to return to work earlier, however, hasn’t happened in reality.

The British Medical Association (BMA) has been highly critical of the language used by the government when describing the fit for work service. The association said it was “misleading” to claim that fit for work was offering “occupational health advice and support” when the emphasis was on sickness absence management and providing a focused return to work.

The idea that work is a “health” outcome is founded on an absurd and circular Conservative logic: it’s an incorrect inference based on the fact that people in work are healthier than those out of work. It’s true that they are, however, the government have yet again confused causes with effects. Work does not make people healthier: it’s simply that healthy people can work and do. People who have long term or chronic illnesses most often can’t work. It has been historically  and empirically established that poverty is closely correlated with disproportionate levels of ill health, and it’s most probable that targeted austerity, leading to increasingly inadequate welfare provision, has made a significant contribution to poorer health outcomes, too.

The government’s main objection to sick leave and illness more generally, is that it costs businesses money. The government remain committed to a supply-side labour market model. However, as inconvenient as it may be, politically and economically, it isn’t ever going to be possible to cure people of serious illnesses by cruelly coercing them into work.The government’s aim to prompt public services to “speak with one voice” is founded on questionable ethics. This proposed multi-agency approach is reductive, rather than being about formulating expansive, coherent, comprehensive and importantly, responsive provision.

This is psychopolitics, not “therapy”. It’s all about (re)defining the experience and reality of a social group to justify dismantling public services (especially welfare), and that is form of gaslighting intended to extend oppressive political control and micromanagement. In linking receipt of welfare with health services and “state therapy,” with the single intended outcome explicitly expressed as employment, the government is purposefully conflating citizen’s widely varied needs with economic outcomes and diktats, isolating people from traditionally non-partisan networks of relatively unconditional support, such as the health service, social services, community services and mental health services.

Public services “speaking with one voice” will invariably make accessing support conditional, and further isolate already marginalised social groups. It will damage trust between people needing support and professionals who are meant to deliver essential public services, rather than simply extending government dogma, prejudices and discrimination.

However, unsatisfactory employment – low-paid, insecure and unfulfilling work – can result in a decline in health and wellbeing, indicating that poverty and growing inequality, rather than unemployment, increases the risk of experiencing poor mental and physical health.

People are experiencing poverty both in work and out of work. Moreover, in countries with an adequate social safety net, poor employment (low pay, short-term contracts), rather than unemployment, has the biggest detrimental impact on mental health. There is ample medical evidence to challenge the current political dogma, and to support this account. (See the Minnesota semi-starvation experiment, for example. The understanding that food deprivation in particular dramatically alters cognitive capacity, emotions, motivation, personality, and that malnutrition directly and predictably affects the mind as well as the body is one of the legacies of the experiment.)

Systematically reducing social security, and increasing conditionality, particularly in the form of punitive benefit sanctions, doesn’t “incentivise” people to look for work. It simply means that people can no longer meet their basic physiological needs, as benefits are calculated to cover only the costs of food, fuel and shelter.Food deprivation is closely correlated with both physical and mental health deterioration. Maslow explained very well that if we cannot meet basic physical needs, we are highly unlikely to be able to meet higher level psychosocial needs.

The government proposal that welfare sanctions will somehow “incentivise” people to look for work is pseudopsychology at its very worst and most dangerous.In the UK, the government’s welfare “reforms” have further reduced social security support, originally calculated to meet only basic physiological needs, which has had an adverse impact on people who rely on what was once a social safety net.

Poverty is linked with negative health outcomes, but it doesn’t follow that employment will alleviate poverty sufficiently to improve health outcomes.In fact record numbers of working families are now in poverty, with two-thirds of people who found work in 2014 taking jobs for less than the living wage, according to the annual report from the Joseph Rowntree Foundation a year ago.

Essential supportive provision is being reduced by conditionally; by linking it to such a narrow outcome – getting a job – and this will reduce every service to nothing more than a political semaphore and service provision to a behaviour modification programme based on punishment, with a range of professionals being politically co-opted as state enforcers.The Government is intending to “signpost the importance of employment as a health outcome in mandates, outcomes frameworks, and interactions with Clinical Commissioning Groups.”

I have pointed out previously that there has never been any research that demonstrates unemployment is a direct cause of ill health or that employment directly improves health, and the existing studies support the the idea that the assumed causality between unemployment and health may actually run in the opposite direction.It’s not that unemployment is causing higher ill health, but that ill health and discrimination are causing higher unemployment. If it were unemployment causing ill health, at a time when the government assures us that employment rates are currently “the highest on record,” why are more people becoming sick?

The answer is that inequality and poverty have increased, and these social conditions, created by government policies, have long been established by research as having a correlational relationship with increasing mental and physical health inequalities. For an excellent, clearly written and focused development of these points, the problem of “hidden” variables and political misinterpretation: see Jonathan Hulme’s, ‘Work won’t set us free‘.


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