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Embargo: Not for release before 00.01 7 January 2005

countering an urban legend

sicknote Britain?

• Section one : introduction
• Section two : what is going on?
• Section three : the public sector
• Section four : stress
• Section five : Incapacity Benefit
• Section six : disguised unemployment?
• Section seven : the union contribution
• Section eight : conclusion
• : references

Section one : introduction

Is Britain a nation of malingerers? Going by some of the newspaper stories of the last few months the answer must be 'yes'. The story has a number of elements, each of which from time to time is the focus of attention, but which hang together:

• British workers take too much time off sick, especially in the public sector,

• Often they claim to have conditions like ‘stress’ that shouldn’t be taken seriously,

• The number of people who get Incapacity Benefit is rocketing - most of them should be looking for work, and

• The Government is hiding the true level of unemployment by not counting them as jobless.

In fact, all these claims are misconceived in one way or another, and this short report takes a careful look at them in turn. We argue:

• British workers do not take a lot of sick leave by international standards;

• Employers recognise that most sickness absence is genuine;

• In fact, many workers go to work when they are too ill;

• If we want to cut sickness absence we should turn our attention to creating better jobs - jobs that are more family friendly and less stressful;

• Sickness absence may be higher than it need be because of Britain’s extreme level of inequality;

• The public sector has a lower level of short-term sick leave than private sector, and the higher level of long-term absence is linked to public sector workers’ stressful jobs;

• Stress is a serious problem, and there is ample evidence that it has a significant effect on health;

• Despite all the attacks on Incapacity Benefit, the number who get IB is falling not rising - the growth in ‘incapacity benefits’ is due to rising numbers of disabled people receiving means-tested Income Support, a much harder benefit to cut;

• Fraud among people receiving IB is uncommon, and the overwhelming majority of beneficiaries face genuine health or impairment-related barriers to employment;

• In the 1980s and 90s IB was used to hide the true level of unemployment, but the current Government is not guilty of this;

• Nonetheless, a strategy to cut economic inactivity must include an active regional policy, aiming to provide jobs in parts of the country hit over the past 25 years by the collapse of traditional industries;

• A positive alternative will also include better health and safety management, active labour market programmes and benefit reforms that aim to help (but not coerce) people back into jobs, a sustained attack on inequality and a strategy to improve the quality of jobs.

Section two : what is going on?

Do British workers take too much sick leave?

International comparisons of sickness absence are uncommon - different medico-legal and social security systems use different definitions, making comparisons difficult. But there have been comparisons that suggest that, far from swinging the lead, British workers are actually much less likely to take sick leave than workers in other European countries. One recent report (Zijlstra and Rook, fig 1) compared the UK with Denmark, Portugal, Italy, Belgium, Germany, France, Netherlands, Norway, Ireland, Sweden and Austria.

• In Britain a lower proportion of working time was lost to short-term absence than in any other country except Denmark, and

• Only Austria, Germany and Ireland lost a lower proportion of working time to long-term absence.

Although they believe that there is still room for improvement, the surveys carried out by the CBI (the employers’ organisation) do not suggest that British workers are taking unjustified days off for 'a majority of absence'. Although their 2004 survey picked up employers’ suspicion that some workers were taking long weekends, it also found that most absence was 'caused by genuine sickness' and that the cost of absence was stable in 2003. (CBI, 2004) Although the time lost through absence per employee rose in 2003, this was in comparison with the results for 2002 - when sickness absence was at its lowest level since the CBI began its surveys in 1987.

A January 2004 poll by BMRB for the TUC (TUC, 2004a) found that 75% of working adults said they had been to work when really they were too ill. There were large majorities saying this in every group of workers - in every region of the country, every age group from 16 to 65 and every social class from AB to E. The most common reason workers gave was that people depended on them and they didn’t want to let anyone down. This is admirable, but presenteeism can be a significant problem - a study of absence in the civil service found that working when you are sick is a route to long-term absence. (Quoted in Pickvance, 2004)

What is more, turning up at work does not guarantee a worker will be effective: an American study carried out during a two-week period in 2003 found that 13% of workers experienced ‘common pain conditions’ like headaches and arthritis, losing an average of 4.6 hours per week - three quarters of which was brought about by lower productivity while at work, not absences. (Stewart et al, 2003, quoted in Pickvance, 2004)

A Dutch poll (Aronnson et al, 2000) found that presenteeism is linked to work pressure. 63.2% of the Dutch work force had gone to work when they thought they should report sick in the previous 12 months, and the higher the work pressure faced by a worker, the more likely s/he was to say this. 92% of those who said that they were always under pressure at work said yes to this question, compared with 50.6% of those who said they were never under pressure. It is interesting that the Netherlands usually figures as one of the European countries with the highest levels of sickness absence - plainly the figures would be even higher if workers felt free to take absences they are entitled to.

If we want to cut sickness absence, enhanced flexibility to promote family-friendly employment, improved work organisation and job design and better management of health and safety would make a more positive contribution than a crack down on absenteeism. The Government has recognised that '’Bad’ jobs may make people ill', pointing to 'persuasive evidence' that 'a lack of job control, monotonous and repetitive work, and an imbalance between effort and reward are associated with a higher risk of coronary heart disease and other health problems. And, although work is generally good for people’s health, poor health and safety management increases the risk of occupational diseases and injury.' (DH, 2004, 159)

Progress on reducing Britain’s pervasive inequality and concentrations of poverty would also make a difference to the mental health and cardio-vascular conditions that are major causes of sickness absence. Sir Michael Marmot, probably Britain’s leading epidemiologist, has pointed out (Marmot, 2004) that 'sustained, chronic and long-term stress is linked to low control over life circumstances', which in turn is linked to low social status.

Sir Michael ran studies of stress levels in Whitehall civil servants from1967 - 1985, which showed that there is a clear ‘social gradient’ in life expectancy among civil servants: the higher your grade, the longer you were likely to live. The reduced level of control over one’s job found in the lower grades of the civil service is linked to higher stress levels, and stress is linked to diabetes, high blood pressure and heart disease via increased heart rates and other responses such as the release of adrenaline. There is a strong link between civil service grade and health, being in a lower grade is associated with a higher incidence of heart disease, some cancers, depression and, importantly for this briefing, sickness absence. (Ferrie, 2004)

This insight applies to communities as well as individuals. Marmot has also suggested that status anxiety and the social gradient may explain why poorer but more equal countries like Greece and Malta have higher life expectancy rates than the UK or the US. In this country, however deprivation is measured, the prevalence of coronary heart disease and anxiety is linked to increasing deprivation. (Hoare, 2003) Both of these conditions are strongly linked to sickness absence.

To summarise this section:

• By international standards British workers do not take large amounts of sick leave,

• Instead they often go to work even though they are ill, and

• There would be less sickness absence if we could reduce our levels of inequality and improve the quality of workers’ jobs - especially by increasing workers’ autonomy and control over their own jobs.

The debate about sick notes is one that should concern all anti-poverty campaigners: the social gradient means that the attack on sickness absence is, disproportionately, an attack on the poor:

'While poverty is measured in terms of money, it is not just about money. Almost anything bad you can think of, poor people have more of it. More illness, more accidents, more crime, fewer opportunities for their children and the most fantastically expensive credit' (Nickell, 2004, C1).

Section three : the public sector

Sickness absence is well managed in the public sector, and the workers are not taking more ‘sickies’: short-term absence levels are lower than in the private sector. Long-term absence is higher, but this is directly related to public sector workers’ stressful jobs.

It is when short-term and long-term absence are added together that figures show the overall rate of sickness absence as higher in the public sector. That is why the most recent CBI survey, for instance, shows public sector absence averaging 8.9 days a year per employee, compared with 6.9 days for the private sector.

There is nothing mistaken or misreported about this figure - the Government’s most recent review (HSE, 2004) actually estimated a higher figure, of 10 days for the civil service, with 'similar levels of sickness absence … in other parts of the public sector.' But simple comparisons don’t really measure like against like. Firstly, whether in the public or private sector, larger employers tend to have higher levels of absence - the CBI survey found that employers with over 5,000 employees averaged 10.2 days, compared with an average of 4.2 days for organisations with under 50 employees. A report using CIPD data from 2002 also found a difference related to the size of the organisation:

Sickness absence rates by organisation size

	Days lost per employee per annum
1 - 500 employees	8.9
500+ employees	10.7

(Zijlstra and Rook, 2003, table 1)

This may be, as some have speculated, because employers in smaller organisations are closer to their workers and there is more peer pressure from colleagues, but it may also be a result of the fact that larger organisations have more personnel resources, and are better at monitoring absence and keeping records. All employers under-report sickness absence, and one of the first things that happens when an organisation starts devoting more resources to absence management is that record-keeping improves. (One reason why the most recent CBI survey showed an increase in absence may be that more organisations are now paying more attention to the issue.)

Separating out manufacturing (where enterprises tend to be larger than the average for the private sector) helps underline this point. Similarly, when compared with non-profit organisations (often operating in very similar fields and providing overlapping services), the public sector has very similar absence levels:

Absence levels by sector

	Average days lost per employee per year
Survey average	9.1
All manufacturing and production	9.2
All private services	7.8
All public services	10.7

(CIPD, 2004, table 1)

When we think of unjustified sickness absence we may imagine someone staying in bed and lengthening their weekend by a day or two. If we’re more enlightened, we may imagine someone with little control over their work pattern forced to phone in sick by a conflict between work and family. However it is thought of, if the ‘sickie’ is a matter of a day or two off, then it’s the private sector that has the problem: the private sector loses, on average 5.5 days per worker per year to short-term absences (of five days or less), compared with 4.9 in the public sector.

' The public sector has higher recorded long term (certificated) absence rate than the private sector - as one might expect given the more generous entitlement to occupational sick pay for long absences. And it is long-term sickness absence (particularly stress related) that appears to have deteriorated in recent years: the percentage of individuals experiencing spells of long term (21+day) absence has increased from 5% in 2001 to 5.7% in 2003 - 44% of all days lost. ' (HSE, 2004, 10)

And finally, public sector workers do jobs that are more likely to be associated with absence. In 2004 psychology firm Robertson Cooper published the results of a survey of 25,000 people in 26 jobs that confounded many common assumptions about how stressful different jobs are. Senior business directors - with pressured jobs, but lots of control over those jobs and recognition for the work they do - actually came bottom of this league. Generally speaking, people with higher status jobs tended to have more job satisfaction, better health and less stress, while the most stressed jobs were those dealing directly with customers, especially in emotionally intense situations. While some of the jobs with very high stress ratings - like call centre operators - are found in both the public and private sectors, others are overwhelmingly public sector: paramedics, social workers, teachers, police and prison officers. (Robertson Cooper, 2004).

This confirmed an earlier analysis of HSE statistics (IRS, 2003) that found an increase in stress-related illness, with high scores for teachers (especially nursery and primary), research professionals and protective service occupations such as the police. To sum up this section:

• Levels of short-term absence (the type that is most amenable to effective management) are lower in the public sector;

• The higher overall levels of absence are the result of long-term absence;

• This may have a lot to do with the fact that many public sector jobs are stressful.

Section four : stress

Now One Million Are ‘Too Stressed to Work’

(Headline in the Daily Mail, 11-12-04)

One of the constant features of this debate is the notion that many people nowadays are claiming to be incapable of paid work when the conditions they have are not really that serious. To support this claim commentators often quote the fact that many people on Incapacity Benefit have conditions such as depression or musculoskeletal or cardio-respiratory problems, which are not necessarily an insurmountable barrier to paid work, given the right support (DH, 2004, 156).

In fact, the UK is not unusual in this respect:

• In Austria, the commonest reasons for invalidity and incapacity are musculoskeletal diseases, psychiatric diseases and diseases of the circulation system. (Lang & Reischl et al, 2003, 7)

• In Finland, the biggest causes of sickness absence and disability and early retirement are musculoskeletal and mental disorders. (Joensuu et al, 2003, fig.s 1 - 3)

• In the Netherlands, the biggest groups for WAO disability benefits are people with psychological conditions, ‘locomotor apparatus’ problems, injuries and circulation problems. (Brenninkmeijer et al, 2003, table 5)

Unions are particularly concerned about attempts to minimise the significance of these conditions because they are precisely the commonest problems caused or exacerbated by work. Official figures from the health and Safety Executive show that 2.3 million people say they have a condition caused or made worse by their current or previous work:

Work-related ill health in Britain, 2001-2

Type of work-related illness	Number of workers affected
Musculo-skeletal disorders: strains and pains in the back, upper and lower limbs, hands and fingers	1,126,000
Stress, depression or anxiety	563,000
Breathing and lung problems, including asthma	168,000
Hearing problems, including deafness and tinnitus	87,000
Heart disease, heart attack or other circulatory system problem	80,000
Headache and/or eyestrain	54,000
Skin problems	39,000
Infectious diseases	33,000
Other complaints	171,000
Total	2,321,000

(TUC, 2004a, table 0.1)

What is more, UK employment rates for people with these conditions are well below the average for the population generally, suggesting that people who have them face real difficulties getting jobs, whatever their theoretical opportunities. In 2003, the employment rate for the general population was over 74%. For these groups of disabled people it was much lower:

Employment rates for disabled people

Type of main disability			Employment rate (%)
Problems with	...Arms, hands		53
	…Legs, feet		45
	…Back, neck		47
Heart, blood pressure			56
Mental illness			21

(DRC, 2004a, table 9)

Employment plainly isn’t out of the question, but equally its obviously unfair to accuse anyone with one of these conditions of avoiding work if they haven’t got a job. There seems to have been some grudging recognition of this, with a number of commentators instead picking on stress as an obviously overblown problem. From the headline this section began with, it is plain that some see the large numbers affected as a sign that it isn’t a serious problem (a rather peculiar way of looking at the world, it must be said.) Stress is, in fact a serious issue, and it is particularly important in relation to public sector sickness absence.

In 1999 the Health and Safety Executive estimated that work-related stress cost UK employers at least £353m a year, and cost society at least £3.7bn. (MacKay et al, 2004, 91) Reviewing the scientific literature, the authors found that we can explain why stress makes people ill. They concluded that 'there is now much evidence that demonstrates that there are a multitude of biological processes that mediate the pathways between stress and various disease states (both physical and psychological).' They quote three major surveys of the literature in support. And epidemiological and psychosocial evidence makes the link to work - the authors quote surveys showing adverse outcomes for mental health, general physical health, immune functioning and blood pressure levels. (Ibid, 97)

The major UK survey of work-related stress, carried out by Bristol University (HSE, 2000) found that one worker in five reported occupational stress at very or extremely high levels, and that this was closely linked to chronic ill health. The most recent European Survey on Working Conditions (EFILWC, 2000) found that, across Europe, stress is the second most common work-related health problem, after back pain. Like many other reports, they found that work organisation and management are vitally important - with the commonest stressors being:

• Over- and under-load;

• Inadequate time to complete work;

• Lack of a clear job description, or chain of command;

• No recognition, or reward, for good job performance;

• No opportunity to voice complaints;

• Many responsibilities, but little authority or decision-making capacity;

• Uncooperative or unsupportive superiors, co-workers, or subordinates;

• No control, or pride, over the finished product of work;

• Job insecurity and no permanence of position;

• Exposure to prejudice regarding age, gender, race, ethnicity, or religion;

• Exposure to violence, threats or bullying;

• Unpleasant or hazardous physical work conditions;

• No opportunity to utilise personal talents or abilities effectively; or

• Chances of a small error or momentary lapse of attention having serious consequences.

(EIRO, 2001, 1)

Stress is now the most important cause of sickness absence among local government workers (Employers’ Organisation, 2004, 3), responsible for a fifth of short-term absence and more than a third of long-term - which, as we have seen, is where the public sector problem lies.

The stress epidemic may well be linked to the intensification of work that many commentators have noticed. The CIPD survey found that the most commonly listed causes of stress at work were workloads and ' management style/relationships at work' with 'organisational change and pressure to meet targets' being mentioned frequently. (CIPD, 2004, 35) Stress may be a particularly important issue for public sector workers because so many of them are dealing with major organisational change - such as the civil service efficiency review.

Section five : Incapacity Benefit

Is Incapacity Benefit out of control?

As we will show in this section, the number of people who are getting Incapacity Benefit is falling, not rising. This is the opposite of the message we seem to get from newspapers and politicians, and has been caused by confusion between IB and ‘incapacity benefits’ more generally.

This is the background to claims that the problem is that Incapacity Benefit is just too generous. In fact, the average weekly amount paid to beneficiaries is just £84.28, and this average includes people with protected rates of benefit because their claim began before the benefit was cut in 1995 and again in 2001 - an average of people whose claim began more recently would be even lower. This reality is not mentioned when TV programmes and articles show us seemingly fit people with an easy life on Incapacity Benefit, as if this was the norm. It then becomes easy for the Opposition’s work and pensions spokesperson David Willetts to say that the Government has 'lost a grip on Incapacity Benefit'. (Daily Mail, 11-12-04)

What is really going on? Unfortunately, this is one of those issues where the terminology is confusing. In Britain, the income replacement benefit for many sick and disabled people of working age is Incapacity Benefit:

• Generally speaking, to receive IB you have to pass a test showing that you are ‘incapable of work’ and must also have paid enough National Insurance Contributions.

• Severe Disablement Allowance used to be an alternative benefit for people who hadn’t paid enough Contributions, but it was abolished for most new claimants in 2001 and the people who get it now were either already getting it then (they have protected rights) or became incapable of work in their youth.

• For other people of working age the main benefit is means-tested Income Support with a disability premium (which means that you get a somewhat higher rate of IS).

• In addition to these, other benefits for sick and disabled people include: Statutory Sick Pay, war pensions and industrial injury benefits, which are sometimes included in discussions about benefits for sick and disabled people.

• And there are benefits that aren’t designed as an income replacement, such as Disability Living Allowance, that can be brought into discussions about 'disability benefits'.

As we can see, only one of these benefits is called Incapacity Benefit. But IB, SDA and IS with a disability premium are frequently referred to as 'incapacity benefits'. The Government is largely to blame for this confusion, and it is not surprising that journalists often talk about Incapacity Benefit when they mean 'incapacity benefits', and vice versa - Ministers themselves sometimes make this mistake.

This would be a trivial gripe if it were not for the fact that it leads to policy debates that are based on a false premise. Nearly all the proposals that have emerged in the press have begun by pointing to the growing number of people getting benefit, and then moved on to discussions about reforming IB. But the number of people who get Incapacity Benefit isn’t growing - it is falling. The increase is in 'incapacity benefits'. If IB hasn’t caused the increase, then reforming it won’t solve the problem.

To illustrate, let us look at an Early Day Motion produced by the Conservative front bench at the end of 2004:

'That this House notes that the number of claimants of incapacity benefit has increased by 34,400 since May 1997; further notes that the number of working age claimants as a percentage of the total working age population has increased from 6.4 per cent in May 1997 to 6.8 per cent in May 2004; is concerned that the Government's Pathways to Work pilots have no specific performance indicators; calls on the Government to publish details of the interim findings to date; and urges the Government to make it clear whether it has any plans to put time limits on payments of incapacity benefit.' (EDM 208, ‘Incapacity Benefit’)

The Opposition’s figures are a statistical sleight of hand. Why? Because their figures exclude SDA, which has been effectively been merged with IB. Take the two benefits together, and there is a fall:

Numbers of IB and SDA claimants

Benefit	May 1997	May 2004	Change
Incapacity Benefit	2,370,500	2,404,900	+ 34,400
Severe Disablement Allowance	368,700	303,800	- 64,900
Net	2,739,200	2,708,700	- 30,500

(DWP, 2004a, tables IB1.2 and SDA1.1. We use the figures available to the opposition when they put down their EDM, since then new figures have become available that are more favourable to the Government.)

More importantly, we need to distinguish between the number of people who claim a benefit, and the number actually in receipt of it, which is, after all, what really concerns people. During the same period the number of IB beneficiaries has fallen by 265,000 and the number of SDA beneficiaries by 66,600, (ibid, tables IB1.1 and SDA1.1) a total fall of just under a third of a million:

Numbers of IB and SDA beneficiaries

Benefit	May 1997	May 2004	Change
Incapacity Benefit	1,732,700	1,478,800	- 253,300
Severe Disablement Allowance	367,100	303,300	- 63,800
Net	2,099,800	1,782,100	- 317,700

Why isn’t the Government making more of this? The answer seems to lie in the distinction between Incapacity Benefit and 'incapacity benefits' - the statistics for Incapacity Benefit beneficiaries do not include people who claim for National Insurance ‘Credits’. These Credits help people to build up their pension entitlement even though they can’t pay National Insurance Contributions because they are unemployed or sick or disabled. A surprisingly large number of IB claimants are listed as ‘Credits only’ in the official figures.

In May 1997 there were 628,100 ‘Credits only’ IB claimants, and, by August 2004 this had risen to 924,100. (Ibid, table IB1.3) Some of these claimants will not be getting any actual benefits (because, for instance, of the level of occupational pension they receive) but five out of every six receive Income Support with a disability premium. And the number of people receiving Income Support with a disability premium has increased substantially - from 827,000 in May 1997, to 1,121,000 in August 2004 (DWP, 2004b, table IS2.7), an increase of 294,000, though this figure includes children receiving the Enhanced Disability Premium brought in by the current government.

One reason for the increase in the number of people receiving Income Support with a disability premium may well be the fact that the Incapacity Benefit rules were tightened significantly in 1995 and 2001. Restricting eligibility doesn’t make people who have genuine illnesses and impairments get better - they just have to apply for a different benefit.

This leaves us with a puzzle: the number of people receiving Incapacity Benefit is coming down, but newspaper reports and TV programmes repeatedly talk about reform of IB as the answer to rising numbers on 'incapacity benefits'. Part of the answer must be entirely understandable confusion among journalists who don’t deal with the benefits system regularly. But part of the answer is also that the disability premium is a harder target than Incapacity Benefit. 189,000 beneficiaries are people with impairments that also qualify them for the Severe Disability Premium, (ibid, table IS6.1) and it can hardly be anyone’s intention to target this group. Also, by definition, people receiving Income Support are poor, and disabled recipients are likely to be among the most vulnerable of the poor - even the hardest-hearted person is unlikely to warm to a campaign to cut their benefits. Politicians chasing media support with a crack down on Incapacity Benefit could easily find that there is another side to these stories:

'STROKE MAN TOLD: FIND JOB

Bob Gascoigne’s benefit was axed and he was told to get a job — despite suffering a heart attack and a stroke…'

The Sun, 17 - 12 - 04

Pathways to Work

One could imagine a response to this argument that accepted that reforming Incapacity Benefit is not the best strategy for attacking the increasing numbers of beneficiaries of incapacity benefits, but that it is a way to reduce the overall level. To which the answer is that this is already happening, in the form of the ‘Pathways to Work’ programme, introduced in October 2003. The main elements of these pilot projects are:

• Mandatory Work Focused Interviews for Incapacity Benefit beneficiaries;

• A £40 per week Return to Work Credit for up to a year for IB beneficiaries who get jobs;

• New specialist IB Personal Advisers, focused on helping people back to employment;

• A set of ‘Condition management’ programmes, much better than ordinary rehabilitation provision;

• A ‘Choices’ package of extra support.

2004’s Opportunity for All report described Pathways as 'a cutting-edge, joined-up approach …. early evidence shows that thousands have already been helped into work' (DWP, 2004c, 9) and promised that 'we will develop the Pathways to Work pilots.' (Ibid, p 10) Touchbase, the Department’s internal magazine, has been equally positive, informing readers that 'IB PAs report that, by dealing positively with customers’ attitudes to their health condition, there has been a marked change in outlook. ‘Customers are more responsive and are focusing on their capabilities rather than their disabilities. They now see a return to work as achievable.’' (DWP, 2004e, 12) This promise was repeated in the 2004 Pre Budget Report, which announced 'a major expansion of the Pathways to Work pilots for incapacity benefits claimants to an additional 14 Jobcentre Plus districts covering the thirty Local Authority Districts with the highest concentrations of incapacity benefits claimants, thereby extending this groundbreaking approach to around one-third of the country'. (HMT, 2004, 71)

This is not just Government ‘spin’ - the first independent study (Dickens et al, 2004 and DWP, 2004d) also suggests that the pilots are preferable to a ‘clampdown’ demanded by some newspapers:

• Double the number of people were getting jobs through Jobcentre Plus compared to the previous year.

• Participants were positive about the supportive elements of the programme, especially the Return to Work Credit;

• In pilot areas five times as many people as previously were joining the New Deal for Disabled People and other special back-to-work programmes for disabled people.

But shouldn’t people on Incapacity Benefit be made to look for jobs?

Ministers often emphasise the fact that more than three million disabled people are in employment and official surveys show that there are another million who want to move into jobs. Some research has suggested that many people covered by the survey respond ‘idealistically’ when asked about paid work, and others say they would like a job ‘out of financial necessity’ (Reith, 2004, 8 - 9), and so the ‘realistic’ number may be significantly lower than a million.

Even so, this is a large and important group and policies to help them are well worth supporting, but it is not going to be an easy task. Politicians should concentrate on supporting this group before turning their attention to the two million working age sick and disabled people who do not want jobs (calculated from DWP, 2003 para.s 75 - 6).

Some of these sick and disabled people may have concluded that their conditions rule out paid work. The movement for disabled people’s rights has repeatedly shown that the large majority of working age disabled people are capable of paid employment on an equal basis, and has campaigned for anti-discrimination legislation to turn that ability into a right. But people whose condition causes them pain or fatigue should not have to look for (or stay in) employment. We would not accept this if an employer required it of an employee whose sickness or injury put them in this position temporarily, and the argument applies even more strongly where someone’s condition is long-term or permanent.

Other claimants will have decided, on the basis of their experience of discrimination and exclusion that, in practice, they are not going to get jobs. In principal, a non-discriminatory society would guarantee equal employment opportunities to disabled people, who therefore should have an equal duty to seek employment. But we have not yet achieved the level of equal rights that would make it fair to apply equal employment duties in this way.

And, in practice, we know that the people currently claiming incapacity benefits would face severe difficulties if they were forced to apply for jobs like unemployed people. In 2001 the Department for Work and Pensions published the results of a survey (Ashworth et al) of people who moved from Incapacity Benefit to Jobseeker's Allowance. This is a group who could be expected to be much closer to the labour market than IB claimants generally, but they still found getting jobs very difficult:

• On average, 28% of all disabled and non-disabled people claiming JSA were still on the benefit a year later.

• But, for people who moved there from IB, the figure was 45%.

• This was despite the fact that they were very committed to employment, and more likely than other people on JSA to say that they would accept any job they could get (39%, compared with 32%).

We know that the problems IB claimants face in getting jobs are actually much more severe than the media stories about malingerers would ever suggest. Far from having trivial or mild conditions, researchers have found that, when the impairments of claimants of incapacity benefits were ranked on a severity scale ranging from zero to ten, over half had a severity score of five or higher. The survey also found that 64 percent of the participants said their condition had been affecting their ability to do paid work for more than five years, and 90 percent expected their conditions to last for at least another year. (Loumidis et al, 2001, 18 & 20)

Commentators and politicians frequently express surprise at the rising number of disabled people. There is certainly a debate about why this is happening, but the fact is undeniable.A widely noted Bank of England study found that disability became more common in the 1990s; the census and the Labour Force survey gave different numbers, but both found that the proportion of people who had a limiting long-term illness increased by about 50% between 1991 and 2001. (Bell and Smith, 2004, 16) The Disability Rights Commission recently revised its figure for the total number of disabled people in Britain up from 8.6 million to 10 million. (DRC, 2004b, 1)

And finally, everyone should recognise that there is a very low level of Incapacity Benefit fraud. As the official benefit review of Incapacity Benefit noted:

'Due to the small number of confirmed fraud cases found during the review, it is not possible to produce a robust central estimate of the total annual value of benefit overpaid due to fraud for short-term Incapacity Benefit and long-term Incapacity Benefit. However, an indicative upper limit has been produced. It is estimated that the amount of overpayment is less than £19m, i.e. less than 0.3% of all expenditure on cases in receipt of these rates of IB. Similarly, it is estimated that the percentage of all IBST(H) and IBLT cases that are fraudulent is less than 0.5%.' ( ONS, 2001, para 2.2. )

From time to time it is suggested that there is something suspicious about the fact that many claimants of incapacity benefits previously claimed JSA, rather than having left employment because of their conditions. In 2001 the DWP sponsored research into people moving between Incapacity Benefit and Jobseeker's Allowance. The results directly contradicted this assumption and the negative anecdotal evidence often quoted in support of it:

'Moves from JSA to IB/IS among claimants in our sample mostly seem to have been appropriate, and were usually caused by the onset, recurrence or deterioration of a health problem. Both BA and ES staff allege a range of situations in which this move is made inappropriately in an attempt to manipulate the system, but there were few signs of this in the research. Such cases no doubt exist and should be dealt with, but we suspect they may be fairly marginal in numbers.' (Hedges and Sykes, 2001, 2. )

Section six : disguised unemployment?

Isn’t the Government hiding unemployment?

One of the themes of the discussions about ‘sicknote Britain’ has been the repeated suggestion that the Government is relying on the large numbers of people who are long-term sick/disabled to disguise the true level of unemployment.

'The more who claim incapacity benefit, the fewer appear in the jobless figures - allowing Ministers to boast of creating full employment.' (Daily Mail, leader, 16-12-04)

'We remember being accused of taking people off unemployment benefits and putting them on to disability benefits—but what do we see now? We see an increasing number of people on disability benefits and an increasing number claiming incapacity benefit. I have seen the figures.' (David Willetts MP,Commons Hansard, 24 Feb 2004, Column 166)

The Labour Force Survey (LFS), which uses the ILO’s agreed international definitions, classifies people as either economically active or economically inactive. To be economically active you have to be either employed or unemployed, and to be unemployed you have to be available for work and seeking it. Economically inactive people either do not want paid jobs, or are not available for them or are not looking for them. The LFS asks people who are economically inactive because they are not looking for jobs or not available for work whether they would nonetheless like a job. Over the past 33 years the number of economically inactive people has not varied much, usually within half a million of 7.5 million people. The economic inactivity rate (the proportion of people of working age who are economically inactive) has also been quite steady, with the extremes being 19.3% (in 1989 and 1990) and 23.3% (in 1983). (Lindsay, 2005, 4)

There is an obvious advantage for a Government that is worried about the political impact of high unemployment to be gained by encouraging people without jobs to apply for incapacity benefits, which require them to become economically inactive, instead of unemployed.

And, historically, this has undoubtedly been an issue in the UK. In our 2003 report Inactive Britain, we pointed out that, by European standards, this country has a high proportion of economically inactive people who want jobs. (We do not include economically inactive people who do not want jobs in this discussion because they cannot realistically be included in effective labour market slack.) Although Britain has made very good progress in cutting unemployment, and now has a lower unemployment rate than most other European countries, our ‘want work rate’ does not compare so well:

‘Want Work Rates’ across Europe 2002

Country	Rate
Italy	15.90%
Spain	14.70%
Finland	14.50%
Luxembourg	11.50%
UK	11.40%
Germany	11.30%
Greece	9.80%
France	9.60%
Ireland	9.20%
Belgium	9.20%
Austria	7.60%
Denmark	7.10%
Sweden	6.60%
Portugal	6.50%
Netherlands	5.10%
EU15	11.50%

(The ‘want work rate’ is calculated in a similar way to the unemployment rate - those who are unemployed or economically inactive but want a job, as a proportion of those who are economically active or economically inactive but want a job. This table is taken from Inactive Britain, p 17.

)

Over time the composition of the economically inactive has been changing. At one time by far the commonest reason given was that people were not available for or seeking employment because they were looking after their family/home. As women’s participation in the labour market has increased, so the number giving this reason has come down. But the overall number of economically inactive people has stayed much the same because the number of sick and disabled people has been rising. In Spring 2004, economic inactivity among people of working age broke down as follows:

Economic inactivity

Student	21.2%
Looking after family/home	29.9%
Temporary sick	2.5%
Long-term sick	27.5%
Discouraged workers	0.4%
Retired	7.6%
Other	10.8%
Does not want a job	74.2%
Wants a job	25.8%

Sickness and disability has come to be called ‘hidden unemployment’ by some people. The TUC does not use this phrase because it suggests that the Government is deliberately hiding it. We know that this did happen in the 1980s and 1990s. As Beatty and Fothergill, the leading advocates of the concept of hidden unemployment have pointed out, (Beatty and Fothergill, 2004, 7) there were more than thirty changes in the rules for unemployment benefit, mainly designed to reduce the claimant count figure for unemployment. In earlier work they showed that there was a 'diversion from unemployment to sickness benefits' in the UK coalfields after the pit closures of the 1980s. (Ibid, 7) Indeed, it was an open secret at the time that Employment Service managers were strongly encouraged to promote Invalidity Benefit (the predecessor of Incapacity Benefit) as a preferable alternative to Unemployment Benefit.

But there is no reputable evidence that the current Government is doing this. Indeed, given their strong efforts (and heavy investment in Pathways to Work and other programmes) to encourage disabled people into jobsearch, this would be unintelligible. As Beatty and Fothergill recognise, 'the big increase in the number of working-age men claiming sickness-related benefits was primarily a phenomenon of the 1980s and early 1990s.' (Ibid, 6) Part of the growth in the number of people claiming incapacity benefits is among women (a 182,000 increase between 1995 and 2004) and the Beatty-Fothergill thesis has little to say about this.

Beatty and Fothergill tend not to address the severity of the impairments and ill health of many Incapacity Benefit claimants. The evidence we quoted above about the difficulties Incapacity Benefit claimants face in getting jobs suggests that there is an advantage in keeping economically inactive sick and disabled people who want jobs conceptually separate from unemployed people with a health problem or impairment. Yes, active labour market programmes can help both groups of people into jobs, and neither should be written off as far as the hope of employment is concerned. But it is entirely reasonable to pay extra attention to the obstacles faced by economically inactive sick and disabled people, and to apply a different regime of responsibilities to them. Requiring the people who currently get Incapacity Benefit to look for work in the same way as Jobseeker's Allowance beneficiaries would force them to apply for job after job they would not get. The stress and uncertainty of this would be unfair and frequently make their health conditions worse.

But this should not be taken as implying that we disagree entirely with Beatty and Fothergill’s analysis. Indeed, we strongly support one of their most important contentions: that an attack on this aspect of economic inactivity will require more efforts to create jobs in the areas where economically inactive sick and disabled people live. As they show, the districts with a high proportion of the total working age population claiming sickness-related benefits are mainly those 'where industrial job losses have been concentrated over many years and where claimant unemployment has persistently been higher than the national average.' (Ibid, 10) Unions would add that, in these former mining towns and villages, and in districts that previously hosted heavy industries, one of the inheritances that communities still have to live with is a particularly high level of work-related ill health.

Beatty and Fothergill’s table of the districts with the highest and lowest sickness claimant rates in August 2003 is particularly persuasive:

Districts with the highest and lowest sickness claimant rates, Aug 2003

District	% of total working age population
Top 10
Easington	21.1
Merthyr Tydfil	20.7
Blaenau Gwent	19.1
Neath Port Talbot	17.2
Glasgow	17.2
Rhondda Cynon Taff	16.7
Liverpool	16.1
Knowsley	16.0
Caerphilly	15.6
Bridgend	14.7
Bottom 10
Surrey Heath	2.8
Wycombe	2.8
Vale of White Horse	2.8
Elmbridge	2.8
West Berkshire	2.7
Waverley	2.7
South Cambridgeshire	2.7
Wokingham	2.0
Hart	1.7

Source: Ibid, table 1

We might quibble about the assumption that people have been ‘diverted’ onto sickness benefits, but we would agree with the rest of Beatty and Fothergill’s summation of the implications of their study:

'There is an inexorable logic here that points to regional economic policy as the way forward. The pressing need is for policies that divert incremental demand for labour to the parts of the country where there remains substantial labour market slack among the claimant unemployed but more particularly among the very large numbers diverted onto sickness benefits. Indeed, with full employment in parts of the South, regional economic policy is arguably now the essential tool to achieve the government’s stated goal of full employment.' ( Ibid, 22)

Section seven : the union contribution

In the next section we conclude by bringing together a positive and supportive alternative approach to cutting sickness absence. The TUC believes that unions have a great deal to offer any Government willing to take such an approach, especially by promoting health and safety at work.

We know that workplaces that have safety representatives appointed by the union and joint health and safety committees with the management have fewer than half as many workplace injuries as their non-union counterparts. (Reilly et al, 1995) Unions can help organisations manage sickness effectively: in promoting rehabilitation, return-to-work planning, monitoring progress and in discussions about adjustments to or changes of job responsibilities. Unions can help fashion family-friendly policies or deal with conflicts at work to reduce the risk that cause workers to take absences that aren’t justified by their health conditions. Unions regularly issue advice and guidance on issues like workplace stress (TUC, 1998, 2002) or alcohol and drugs (TUC, 2001) and we know from our day-to-day experience that employers regularly turn to us for advice and expertise on health and safety problems.

We believe that a great deal more could be done to remove workplace causes of ill health and absence. And this would be a sensible investment - f ewer than 20 per cent of working-age disabled people were born with their impairments (Stanley and Regan, 2003, s 3). The TUC supports a ‘preventative’ approach - enhancing rehabilitation and other services that help people who become disabled (or whose condition deteriorates) to remain in their jobs. Unfortunately, British rehabilitation services are uncoordinated and under-resourced: it has been estimated that a worker who has a major injury has a 50% chance of returning to employment in Sweden, 30% in the USA and 15% in Britain. (Ibid, para 3.2)

Section eight : conclusion

…. and a positive alternative

Most of the stories about 'sicknote Britain' are misleading at best:

• International comparisons show that Britain isn’t a nation of malingerers.

• If anything, what we have is a problem of presenteeism.

• Bad jobs and in equality have a lot more to do with sickness absence than swinging the lead.

• The public sector does have more overall sickness absence than the private sector but this is concentrated in long-term absence, when it comes to the short-term absence that is the main target for improved management, the public sector’s record is actually rather better than the private sector.

• Public sector long-term absence is probably caused by the difficult and stressful jobs many public sector workers have.

• The UK is not unusual in seeing increasing numbers of workers saying they suffer from work-related stress - its an international trend.

• It’s a serious issue - medical researchers have found that negative stress really does have serious health consequences.

• The number of people who get Incapacity Benefit is going down not up.

• The Government already has a very good programme for cutting the number of people on incapacity benefits.

• It would in any case be unfair to cut these benefits to force claimants to look for jobs, as most of them face genuine and serious health or disability-related obstacles to employment.

• The Government is not trying to hide unemployment in the economic inactivity figures.

• But there is a connection between the numbers of economically inactive people who want jobs and their availability in the areas where they live.

But, alongside this critique, the TUC has a positive message. Firstly, we strongly support the ‘Pathways to Work’ project because we believe that helping people on incapacity benefits to return to work is an entirely worthwhile endeavour. We would like to see the name ‘Incapacity Benefit’ changed: although we think it would be unfair to require IB beneficiaries to look for jobs, it is a mistake to suggest that employment is out of the question for them.

Secondly, the Government’s efforts to end child poverty are likely, over time to promote greater income equality. This will in turn reduce the level of chronic ill health and disease that follows on from the stresses of poverty and inequality: another reason why unions enthusiastically support the Government’s target of ending child poverty.

Thirdly, in addition to their health and safety expertise, unions by their very nature help to increase the proportion of good jobs in the labour market and cut the proportion of bad jobs. Unions reduce within-firm inequality, sectoral collective bargaining reduces within-sector inequality and organisations that recognise unions have less racial, gender, class and disability inequality. Unions counter pressures for job intensification, over-supervision and the loss of autonomy and control. We press for recognition of workers’ contribution to company success, provide an opportunity to voice complaints and protect employees from brutal or unaccountable managers. Unions promote fairness and healthy working environments, and this contribution should be acknowledged by the Government: a union friendly Britain would be a healthier Britain.

The ‘Pathways to Work’ projects are testing new ideas on retention and rehabilitation, and unions have strongly welcomed this. We have argued that, if these new ideas succeed, this approach should be extended nationwide as quickly as possible. But it is possible to go significantly further - helping people after they have had to give up their job because of their condition is leaving things too late. Greater investment in early intervention and improved occupational health would prevent thousands of workers needing social security benefits in the first place.

What we would like to see is a system that puts prevention first, then offers high quality rehabilitation, with benefits as a generous fall-back when the first two policies have failed and always to be combined with a continuing offer of support in getting back to work. For people who have a health condition or impairment from birth or childhood an integrated system of workplace support is even more important. Organisations that manage health and safety and the return to work effectively are more likely to be able to make access adjustments to health and safety and other procedures and equipment, and thus to be more accommodating workplaces for disabled workers.

Finally, it isn’t just a matter of what, it’s also a matter of how. Unions believe in a system that involves all the workplace stakeholders - unions, employers, occupational health specialists, insurers and, most importantly, disabled workers themselves. Where a worker becomes ill or injured getting her/him back to health as soon as possible should be the first objective, with the injured person being referred for treatment as quickly as possible, with the preferred aim of a return to work. But this is a shift that can only happen if the Government plays a full role. Ultimately the Government will need to provide incentives for the stakeholders to work towards this end. And only the Government can build the rehabilitation infrastructure that would buttress such an approach.

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Report (9,400 words) issued 7 Jan 2005