Access to welfare benefits in primary careBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3642 (Published 17 August 2010) Cite this as: BMJ 2010;341:c3642
- Mark Gabbay, professor of general practice
In the linked study (doi:10.1136/bmj.c3838), Whittaker and colleagues assess variations in primary care patients who claim incapacity benefit, and whether consultation behaviour in primary care can be used to predict those people with mental health problems who are more at risk of becoming dependent on state benefits for long term health problems.1
Internationally the pressure to reduce the proportion of people of working age who depend on state benefits and other benefits is increasing. Recent reviews in the United Kingdom have reported the scale of the problem and associated costs; they have proposed a variety of reforms, some of which, such as the introduction of the new Med 3 certificate (the “fit note”) in April 2010, have already had an effect on sickness certification processes for general practitioners.2 In the UK, the cost of mental ill health in terms of sickness absence, associated benefits, and lost productivity is substantial, and that of absenteeism and presenteeism (being in work when relatively unfit) exceeds the NHS annual budget.2 3 4 Recent guidance from the National Institute for Health and Clinical Excellence (NICE) confirms the lack of robust research to guide practice and government initiatives.5
A recent study of trends in incapacity benefit shows a wide variation in rates across the UK and suggests that the 4% fall in the total number of people on this benefit between 2000 and 2008 reflects fewer new claimants (inflow) rather than more claimants moving back into work, claiming jobseeker’s allowance, or retiring (outflow).6 Another study reported a steady rise in the proportion of claimants with a mental illness, and an association between mental illness and previous unemployment.7 This mirrors the finding that mild to moderate mental health diagnoses are predominant (43% of total days) in sickness certificates and are risk factors for prolonged absence and subsequent incapacity.8
Being out of work is bad for health, and increasing evidence shows that good work (which reflects elements of fair pay and conditions, job control, and satisfaction) is good for health.2 In times of increasing financial pressures and falling employment policy makers attempt to maximise access to good work and reduce the costs and consequences of not having work. Many factors influence the path to work or incapacity, such as work opportunities (range of job vacancies available), support for disabled workers, work (“bad” work) related ill health, the welfare structure and payments system, socioeconomic environments, and cultural expectations. Participants within these structures include the claimants, managers and human resources, practitioners who moderate sickness absence (occupational health, general practitioners, and specialists), and policy makers.
Whittaker and colleagues looked for risk factors related to incapacity benefit claims by analysing data from the Scottish health survey (SHS) and the British household panel survey (BHPS) on the following variables: general practitioner, practice, consultation rate, and claimant demographic and mental health screening (general health questionnaire; GHQ-12).1 This approach, although retrospective, enables the exploration of large, representative, and robust datasets for epidemiological research into associations and trends. The authors found no evidence of substantial variations that might be attributed to differences in general practice certification behaviour. Instead increasing age, being male, deprivation, GHQ caseness (being classified as having a mental health problem by GHQ-12), and high consultation rates before the period of absence were significantly linked to subsequent incapacity benefit awards.1 These findings concur with data from sickness certificate database research.8
What are the implications of these findings? Although targeting individual practices and practitioners may not be an effective intervention, doctors are the key moderators of the route to sickness absence through certification. Their role is at the core of the process to identify those at risk of longer term absence, negotiate certification, and consider referrals to interventions that can facilitate return to work, and thus influence inflow rates to incapacity.
Research shows that decisions about providing sick notes are not straightforward.9 It will be even more challenging to shift the focus during time limited consultations to discuss sickness absence and work modification beyond that required for completion of the new fit note, especially when patients, clinicians, and managers have competing agendas.
The factors that influence flows into and out of incapacity benefit and related benefits are further complicated in people who become sick after unemployment. Studies of such people in receipt of benefits suggest that this is not a simple health related phenomenon. Higher incapacity rates are reported in areas of low employment and a history of industrial job losses.10 A proportion of people on incapacity benefit will therefore find it harder to find work because of their relative disability, work ability, and history of long term unemployment, particularly when the overall job market is more restricted.10
Interventions to reduce absenteeism and incapacity claims for those in employment focus on preventing sickness absence or facilitating return to work through role and workplace modification, occupational health support, case worker support, targeted timely interventions, and negotiations for shorter absence. Evaluations of these interventions must be robust enough to explore the potential for harm as well as benefit, because going to work when not fully fit can harm the person concerned, his or her contacts, and employers.4 This new research is a welcome addition to the existing sparse evidence base. To improve access to welfare for those in need and to support those at risk of drifting into long term unemployment, we need more investment in research that can inform policy and help translate the findings into practical solutions.
Cite this as: BMJ 2010;341:c3642
Competing interests: The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: his employer has received research grants from the UK Department for Work and Pensions; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; through his university MG receives non-commercial research grants to support the work of his research group in this topic area from NHS and UK government related funding bodies, and publishes and speaks on the topic.
Provenance and peer review: Commissioned; not externally peer reviewed.
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