Dr Michael O'Donnell investigates the alarming rise in incapacity in the UK and explains how the country can avert an apparent epidemic
It is a medical paradox of our time that, despite an accelerating rate of medical innovation and technological advances, more and more people of working age are being declared too sick to work. Indeed, the UK could be facing a public health disaster. Although the number of people considered too ill to return to work has stabilised, on any working day nearly six million people are too sick to work. Every week approximately 3,000 people go on long-term Incapacity Benefit - only a small proportion of these people will ever return to work.
During the 70s and 80s when unemployment was rising, incapacity was seen as the preferred option for those out of work. Not only was the benefit allowance more attractive for the unemployed, but also for the Government, as it kept the official unemployment figures artificially low.
However, as unemployment has fallen and demand for labour increased, the number of people claiming incapacity benefit has remained high. Addressing this issue from the perspective of rehabilitation alone is unlikely to resolve the problem, as much more needs to be done to understand exactly what happens when an individual decides they are unable to work.
One way of analysing the problem is from a sociological perspective. In UnumProvident's recent report, Beyond Understanding? Chief Medical Officer's Report 2004: Getting to the root causes of ill health, Dr David Wainwright, senior lecturer in sociology at Bath Spa University College, argues that the modern working life provides less sense of identity and security than the traditional industrial work of previous generations. There is, he believes, a tendency for the stresses of everyday life to become pathological, which may in turn raise the status of chronic incapacity.
Moral imperative
In this way, the 'sick' role has perhaps become more appealing. In the more traditional working environment of previous generations, there was usually a greater sense of camaraderie, which lent a moral imperative to recover as quickly as possible.
With today's less social workplace however, there is significantly less stigma attached to being out of work. The inability to hold down a job is no longer viewed as a moral failing and, in some cases, the identity of being a 'work stress victim' surviving on Incapacity Benefit may confer more status than being long-term unemployed.
Another approach to understanding incapacity is from a psychological perspective, which identifies certain aspects of work that are more likely to be harmful and predispose employees to ill health. In his article for the report, Dr Rob Briner, reader in organisational psychology at Birkbeck College, University of London, argues that the concept of work stress is unhelpful because it oversimplifies a multi-faceted problem - it is impossible to separate the individual from the stress.
However, Briner concedes that, just as being unemployed can be potentially harmful to health, certain low status jobs also have fewer benefits for health than high status ones. This view reiterates Dr Wainwright's point that the perceived lack of status or value of many 'new' jobs contributes to the decision about whether to go to work or stay off sick. Overall, it seems that the current portrayal of work as a potentially malignant source of ill health is particularly damaging and that a fuller understanding is needed of how work is actually good for us.
As one of the pioneers of the bio-psychosocial model of disability, Gordon Waddell, from the Centre for Psychosocial and Disability Research in Cardiff, proposes a new approach. This model attempts to develop a holistic framework to describe how complex factors related to upbringing, personality, expectations, beliefs, and pathology all interact to create the behaviour called illness.
Historically, long-term sickness absence and early retirement on health grounds were due to severe medical conditions with objective evidence of disease and permanent physical or mental impairment. However, these days, common health problems consist primarily of symptoms with limited objective evidence of disease or impairment. With proper management and support, many of these conditions should recover without necessarily leading to long-term incapacity.
The back pain epidemic provides a useful case study. It is a paradox that although work has generally become less physically demanding over the past few generations, the prevalence of low back pain has remained more or less the same, yet chronic disability attributed to back pain has increased exponentially. Therefore, the greatest need, the best opportunity for effective intervention, and the most cost-effective approach is to provide extra help and support to those who are not recovering as expected. This depends on the ability to identify those at risk of developing chronic problems.
By the 1990s, it was widely recognised and accepted that psychosocial factors play a key role in the development of chronic pain and disability. Screening for these factors, also called 'yellow flags', helps to identify those at risk of long-term incapacity - whether through symptoms of back pain or some other ailment - with a view to providing rehabilitation or return to work intervention. Moreover, screening can also help assess how or why certain people are at risk and not others.
In a similar vein, Andrew Potterton, chief medical underwriter at UnumProvident, shows how a review of claimants' medical histories demonstrates that it is not so much what has been seriously wrong with a person in the past that can identify long-term ill health. Instead, it is how many times a person consults a doctor with minor medical problems that most correlates with the risk of claiming for long-term incapacity with medically unexplained or 'functional' illness.
In particular, it seems that family history of such illness appears to be important. Could this mean that a tendency to illness is inherited? Probably not. It is more likely that such behaviour is learnt from an early age from an individual's family.
Early intervention
Overall, we know for certain that return to work is much harder if you have been off sick for a long time. We also know that it is relatively easy to get a sick note. Based on the predictors for long-term incapacity for back pain as listed by Gordon Waddell, pain intensity, psychosocial distress and depression, as well as fear avoidance, are all important predictors of return to work outcomes. Many of these behaviours and beliefs stem from medical advice, and it is often what the person is first told that makes the difference.
Early intervention is important, but it is the first point of contact. It is how the patient is treated by doctors or hospital staff that is crucial. Similarly, employers need to stop the adversarial approach to sickness absence. They can be a powerful factor in enabling an employee to return to work and can do much to identify and remove barriers if they simply take the time to talk to their ill employees. There can be little doubt that engaging with illness in a positive way would make the whole process of dealing with absenteeism far less stressful for all concerned.
We now know some of the predictors of long-term incapacity from both a sociological and psychological perspective. There is a bio-psychosocial model in place that helps to pinpoint those patients at high risk of developing chronic incapacity, and medical histories have been shown to shed light on risk as well.
Does this all mean that in the future we may be able to intervene early enough to prevent long-term incapacity? Although impossible to predict, work in this area continues. For example, the UnumProvident Centre for Psychosocial and Disability Research in Cardiff has been established to probe such questions and, hopefully, generate an even greater understanding of workplace absenteeism and incapacity.
Dr Michael O'Donnell is chief medical officer at UnumProvident
COVER notes
• Every week approximately 3,000 people go onto long-term Incapacity Benefit - only a small proportion of these people will ever return to work.
• The inability to hold down a job is no longer viewed as a moral failing and, in some cases, the identity of being a 'work stress victim' surviving on Incapacity Benefit may confer more status than being long-term unemployed.
• The bio-psychosocial model attempts to develop a holistic framework to describe how complex factors related to upbringing, personality, expectations, beliefs, and pathology all interact to create the behaviour called illness.
