What do we mean by ‘work as a health outcome’?
The quality of work is important. This is as true in terms of productivity and job satisfaction as it is in terms of health. There is a considerable body of research demonstrating how work contributes to health inequalities (the social gradient of health), and, in particular, that unemployment and poor quality work is linked to worse health outcomes. Improving access to good work for all is, therefore, a key public health concern.
This underpins perhaps one of the more contentious elements in the government’s current consultation on work, health and disability – outlined in the ‘Improving Lives’ Green Paper. The call to reinforce work as a health outcome is something which the Work Foundation has long-supported. Support for this premise is not universal, and during the green paper consultations I have been involved in many discussions on this subject. The concerns I hear raised are often completely understandable, for example, the extent to which people will be ‘pushed’ into work they are not able or ready to do, or into bad quality work that is harmful to them, under the misguided notion that any work will be good for them in the long run. Indeed, it sounds rather Orwellian.
It has prompted me to reflect, and expand upon, what work as a health outcome means to me. I hope that in sharing this, it prompts more of you to reflect, and to discuss, what it means from your perspective – and whether you support it or not.
I believe that more people with long-term health conditions and disabilities would be able to work if they were offered the right support, the right job or type of work, and the right work environment. Work as a health outcome is a recognition of that. Working in a good quality job can provide people with not only an income, but with a sense of purpose, self-confidence, independence, fulfilment, and social networks. It can lead to sustainable improvements in individual health and wellbeing and is, along with housing, a key social determinant of health. Despite this, the value work can have is not always well-recognised by the health system – and indeed by us as individuals.
This issue is made more complicated by the implicit knowledge that as a determinant of health, work can be both positive and negative. Though this must be recognised, our research, and that of many others, tells us that too often we look at the negative without recognising the positive, and in doing so take away people’s opportunity to work, rather than thinking about how we can make it work. We know that a period of long-term sickness absence from work can easily result in job loss from which an individual never returns. Often, this is despite the individual wanting to be in work, but feeling like there is little hope in making this work, with employers not seeing a way through (or perhaps being inflexible or unsupportive). Frequently, it ends with a healthcare professional gently explaining that “perhaps, given your health condition, working isn’t really feasible for you”, rather than starting a conversation about what elements of work are difficult, and whether there is anything that can be done to address that. The ‘fit note’ was designed to start this process, but it has proven to not be enough on its own, with little use being made of the ‘may be fit for work’ option.
The goal of recognising work as an outcome is part of a broader aim to change the way we think about disability; focussing more on what people can do, rather than what they can’t, and trying to find solutions to any challenges their health condition presents to people’s lives (including work). With the right support this is possible, but the right support is not always available. By recognising that, despite ill-health, many people want to work, and that working in the right job may improve their health, we can create demand for better support to help more people to work. This is about recognising the opportunities work can offer; not ‘forcing’ people into work.
The way the welfare system works provides a specific challenge, and in particular mandation and conditionality, and the expectation that any job is good enough. If this approach continues (and we have not seen sufficient evidence to suggest it should – particularly for people with disabilities) then care needs to be taken to keep it separate from the ‘work as a health outcome’ agenda. Indeed, we would like to see the separation of health and employability assessments for Employment and Support Allowance. Further, we need to see changes in the way healthcare professionals are trained to ensure that consideration of the social determinants of health forms part of their work, and we need to improve incentives to commission appropriate employment support locally (including through social prescribing and peer support) to help healthcare professionals to get their patients who can work, and want to work, the advice and support they need.
Work as a health outcome is not just about setting targets about employment outcomes for patients. To achieve the cultural change that underpins it will require a change across the health system, and in the way we think about health outcomes. Is recovery from a health condition about alleviation of an individual’s symptoms, or is it about returning – as far as possible – to the same quality of life they had before they became ill?
This is what work as an outcome means to me, and it may not mean the same to you. Even among those who are positive about this concept, definition of what it means varies considerably. What’s important is that we all share our views on what work as an outcome means, and whether we believe it can help us achieve our goal of improving the lives of people with long-term conditions and disabilities. I hope the conversation about work as a health outcome will continue long after the consultation period ends.