Sick of work?
Why millions of Britons have made the 'sicky' into a way of life.
Along with petty pilfering, having the occasional ‘sicky’ has long been a kind of informal profit-sharing, to which employers often turned a blind eye. However, recent research reported that we have become a nation of malingerers, with nearly six million of us too sick to work (1).
The number of people of employable age in receipt of incapacity benefit for longer than six months has quadrupled – from half a million in 1981 to two million in 2002. Sick leave is no longer just a means of obtaining the odd day or two off work. For a large and rapidly expanding proportion of the workforce it represents a new identity, which enables them to opt out of work for long periods of time.
The emergence of this new identity is all the more puzzling because it comes after a century of tremendous improvements in health. We are all living longer and healthier lives – so why are so many of us apparently too sick to work?
One clue comes from regional variations in the numbers claiming sickness benefit. In parts of Wales 25 per cent of working age men are claiming sickness benefit, compared with just five per cent in affluent parts of London. This is partly explained by the legacy of injuries and illnesses associated with the Welsh mining and steel industries. However, such injuries are unlikely to affect a quarter of working age men – and in any case, they would be expected to decline following the collapse of these industries.
Instead, the wide regional disparity in the numbers receiving long-term incapacity benefit could perhaps be explained by economic and cultural factors. Most obviously, employment opportunities in southeast England are substantially greater than those in south Wales, and London’s largely white-collar workforce is more able to take up jobs in the growth industries of services, finance and IT than are the manual workers of Wales. In a climate where jobs opportunities are few, and those that are available require not just re-skilling, but a radical change in occupational identity, it is perhaps not surprising that many will exit the workforce. The question is why so many choose to do so by adopting the sick role.
A key determinant is the incentives of the benefits system. Successive governments, eager to reduce rates of long-term unemployment, have tightened up the system in order to coax the long-term unemployed back to work. For many claimants, incapacity benefit is more generous and sustainable than unemployment benefit, making it a rational choice for those who are not inspired by the limited opportunities usually offered through job centres. The government has responded by trying to tighten up incapacity benefit – for instance, by introducing a means test for new claims. Although this has reduced the number of new claimants, it has provided a strong disincentive for existing claimants to come off the benefit. The result is that the total number in receipt of the benefit has risen.
The transition from long-term unemployment to long-term sickness or disability has only been made possible by a cultural shift in definitions of illness. Physical illness and industrial injuries may be in decline, but psycho-social problems of anxiety, depression and work stress are rapidly increasing, along with a range of new ‘diseases’ such as fibromyalgia, repetitive strain injury, non-specific lower back pain, irritable bowel syndrome and chronic fatigue syndrome, for which evidence of physical pathology cannot usually be found.
The validity of such illnesses cannot usually be conclusively determined by a diagnostic test, with the result that doctors are obliged to rely heavily on the claims made by the patient. The rise of a patient-centred approach to general practice, coupled with the growing popularity of the social model of health and illness, has left many doctors reluctant to challenge their patients’ illness claims. This from a young GP:
‘…if they feel unwell they are unwell. I think the patient defines the disease and just because, either we don’t have the science and technology to prove a physiological change […] just because science isn’t clever enough to show abnormalities, doesn’t mean that there isn’t an underlying physiological problem. For example, a century ago people didn’t know about MS or diabetes and they were told that they were all nutters. But the other thing is even if there isn’t a physiological problem, it doesn’t mean that there isn’t an illness, and if the patient is suffering then we should look at the problem and [see] how we can help.’ (2)
Another study reported in the British Medical Journal suggests that GPs are reluctant to refuse patients’ request for a sick note (3). Some have argued that validation of sick leave should be taken out of the hands of family doctors and given to employers’ occupational health services. The implication is that doctors who are paid by the patient’s employer will have more of an incentive to debunk bogus sickness claims. However, the problem is the broadening of medical diagnostic categories, rather than the failings of particular GPs. If the consensus among the medical profession is that such illness claims are legitimate, then doctors are going to face clinical and legal difficulties in refuting such claims, regardless of who pays their salary.
The broadening of diagnostic categories may have opened the door to the sick role and the benefits system may have elbowed people towards it, but there are other factors behind the rapid increase in long-term sickness. Incapacity benefit may offer marginal financial gains over the equivalent unemployment benefit, but despite what Daily Mail leader writers would have us believe, neither is as rewarding as a job. So why do so many people apparently prefer life off sick to life at work? Malingering and illness deception may be part of the answer (4). But it is only by looking at the way in which society values different identities that we can gain a fuller understanding.
Traditional working-class occupations, such as coal miner or steel worker, were more stable and therefore conferred a much stronger sense of personal identity than the succession of service sector jobs that many working-class people do today. In many respects this loosening of traditional identities is a good thing – who wants their horizons constrained by life in a pit village? The problem is that, while post-industrial society’s emphasis on the portfolio career has improved the fortunes of those able to gain middle-class jobs in the media, IT and management, it has failed to generate a positive identity for those left behind in the working class.
Traditional notions of the dignity of labour or working-class pride have a hollow ring to them when applied to jobs in the call-centre or fast-food outlet. The fragmentation and devaluing of working-class jobs means that they are less likely to be a source of prestige and personal identity. If anything, the identity they give rise to is that of the loser, void of skills or aspirations. This sense of personal detachment from work leads to what the American sociologist Richard Sennett describes as ‘the corrosion of character’ (5).
Pride in one’s work, the desire to perform conscientiously, to be a ‘good’ worker who works hard and carries their weight, all become meaningless phrases, and all that counts is the wage. In this context, sick leave carries no negative consequences for self-identity; there is no sense of letting down one’s colleagues, or of undermining one’s sense of resilience. Where earlier generations would set aside minor illness symptoms and ‘soldier on’, such behaviour is unintelligible to a growing proportion of the workforce.
As the value ascribed to working-class identities has waned, that conferred on the sick role has waxed. Signing off sick has always entailed relinquishing duties and responsibilities for the duration of the illness, but there used to be a moral imperative to get better as soon as possible. Failure to do so was defined as a moral failing and a source of social stigma. Today, the hymning of mental frailty, coupled with a broader cultural shift towards the valorisation of victimhood, has significantly reduced the stigma of idleness. The inability to hold down a job is no longer seen as a moral failing, but as a sign of heightened sensibility.
In a remarkable reversal of the Protestant work ethic, many feel that the identity of the work-stress victim surviving on incapacity benefits confers more prestige than that of the low-paid worker in a dead end job.
Work-life balance issue
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(1) ‘Stress and Work: It’s an ill wind’, The Economist, 3 January 2004
(2) Calnan M, Wainwright D, O’Neill C, Winterbottom A, Watkins C., Upper Limb Disorders and the use of Health Care, MRC:HSRC, Bristol University, December 2003
(3) Hussey S, Hoddinott P, Wilson P, Dowell J, Barbour R. ‘Sickness certification system in the United Kingdom: qualitative study of views of general practitioners in Scotland’, BMJ, 22 December 2003
(4) Halligan PW, Bass C, Oakley D, (Eds.). Malingering and Illness Deception. Oxford: OUP 2003
(5) Sennett, R. The Corrosion of Character: the personal consequences of work in the new capitalism. London: WW Norton & Co 1998
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