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Work, Worklessness, and the Political Economy of Health$

Clare Bambra

Print publication date: 2011

Print ISBN-13: 9780199588299

Published to Oxford Scholarship Online: January 2012

DOI: 10.1093/acprof:oso/9780199588299.001.0001

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Health related worklessness

Health related worklessness

(p.130) Chapter 6 Health related worklessness
Work, Worklessness, and the Political Economy of Health

Clare Bambra

Oxford University Press

Abstract and Keywords

The previous chapter examined how one form of worklessness — unemployment — is associated with an increased risk of ill-health and mortality. This chapter examines the opposite relationship, in which the development of ill-health can result in long-term worklessness. The first section examines health-related worklessness within the UK social security system. Four key issues in current social policy debates about health-related worklessness are then examined: hidden unemployment, cultures of worklessness, the medicalization of sickness absence, and the reserve army of labour thesis. The chapter then examines socio-economic inequalities in the employment consequences of ill-health. The final section takes a more international approach by comparing health-related worklessness by welfare state regime.

Keywords:   ill-health, unemployment, UK, social security system, social policy, health, sickness absence, reserve army of labour

The previous chapter examined how one form of worklessness—unemployment—is associated with an increased risk of ill health and mortality. This chapter examines the opposite relationship, in which the development of ill health can result in long-term worklessness. ‘Health related worklessness’ is thus a term used to refer collectively to people who are out-of-work on a long-term basis (over four weeks) due to a chronic illness or disability (National Institute for Health and Clinical Excellence, 2008). A ‘disability’ in this context is defined as an illness or impairment that limits the usual activities of daily living, including work ability (Organisation for Economic Cooperation and Development, 2009: 11). Across advanced market democracies, poor health is a significant risk factor for unemployment, as well as remaining unemployed. For example, a study using European Community Household Panel Data from the 1990s found that people who developed chronic health problems whilst in employment were twice as likely to become workless within a four year period as those who remained healthy (Schuring et al., 2007). These effects were also noted in a study of health and worklessness in the US (McDonough and Amick, 2001). Over the same period, women in poor health and men in poor health were 60% and 40% less likely to enter paid employment than men in good health (Schuring et al., 2007). In combination with other labour market disadvantages such as low educational level, poor health further increases the risk of worklessness and there are substantial inequalities in health related worklessness (Bartley and Owen, 1996; van der Wel, 2011).

In most advanced market economies, long-term health related worklessness therefore carries an entitlement to receipt of financial support from the welfare state in the form of sickness and disability pensions or, in the case of the UK, incapacity related benefits (as described in Box 6.1). Rates of receipt of these health related benefits have increased across all advanced market economies. For example, in the UK the numbers claiming health related benefits have increased from 0.5 million recipients in 1975 to 2.6 million in 2007. By 2007, around 7% of the UK working age population was in receipt of health related benefits, accounting for 11% of UK social security expenditure, at a cost of around £8 billion per annum and amounting to 1.8% of gross domestic product (GDP) (p.131) (Gabbay et al., 2011). In 2007, 5.8% of the working age population of advanced market democracies (Organisation for Economic Cooperation and Development [OECD] countries) received such benefits (Table 6.1), with an average of 1.2% of GDP spent on long-term disability pensions as well as 0.8% of  GDP on short-term sickness absence, usually paid by employers (Organisation for Economic Cooperation and Development, 2009). The probability of returning to work after being in receipt of long-term health related- benefits is just 2% annually (Organisation for Economic Cooperation and Development, 2003) (p.132)

Table 6.1 Percentage of the working age population in receipt of health related benefits across OECD countries (2007)











Czech Republic




























New Zealand








Slovak Republica








United Kingdom


United Statesa




a 2006.

b 2004.

c 2005.

Source: Data taken from Organisation for Economic Cooperation and Development (2009).

(p.133) with most recipients who have been workless for six months or more having only a 20% chance of returning to work within five years (Wardell and Burton, 2006). The employment rates of people with disability or chronic illness are also much lower, at an average of only 40% across the OECD (in the Netherlands only 10% of disabled people have work as their main source of income as compared to 50% in Sweden [Schuring et al., 2007]), and people with health problems are also more than twice as likely to work part-time (Organisation for Economic Cooperation and Development, 2009). Poverty, social exclusion as well as downward social mobility are also important issues (Acheson, 1998; Myung et al., 2010).

Health related worklessness varies by gender, age, occupation, employment sector, and region (Barham and Begum, 2005). The most common causes of long-term sickness absence among manual workers are acute medical conditions followed by back pain, musculoskeletal injuries, stress and mental health problems. Among non-manual workers the most common causes are stress, acute medical conditions, mental health problems (such as depression and anxiety), musculoskeletal injuries and back pain (Black, 2008), although these are often present as co-morbidities and further complicated by social and employment issues (Bambra, 2010b). In the UK, mild to moderate mental health problems are now more prevalent than musculoskeletal diseases as the prime causes of long-term sickness absence and work incapacity (Shiels et al., 2004). Internationally the pattern is similar, with mental health problems accounting for a third of new disability claims across OECD countries. Mental health is also a more frequent diagnosis amongst younger claimants, amongst those who have never worked and amongst women (Brown et al., 2009; Organisation for Economic Cooperation and Development, 2009). This may well be as a result of more demanding work requirements leading to a greater prevalence of stress related conditions—work intensity increased by 7% across the OECD between 1995 and 2005 (see Chapter 4), as well as problems which individuals with mental health problems face when attempting to find or retain work (Organisation for Economic Cooperation and Development, 2009). Studies of health related worklessness in the UK have found substantial regional variation, with rates highest in areas which have experienced rapid de-industrialisation and the loss of manufacturing jobs (Norman and Bambra, 2007; Brown et al., 2010).

Concern over the rising numbers of people in receipt of health related benefits has meant that health related worklessness has a high political profile in most European countries. However, to date, health related worklessness has been largely ignored by public health researchers, policy makers and practitioners. This is despite the importance of health related worklessness in terms (p.134) of health equity (Schuring et al., 2007), as well as the central role that health practitioners play in terms of certifying sickness absence (Section 6.2.3). Health related worklessness has therefore tended to be framed as a social policy and labour market problem rather than a public health or medical concern (Williams, 2010). This means that much of the academic research has been conducted by social policy specialists, particularly in the UK. This chapter therefore starts by outlining the key material from this field with a particular focus on health related worklessness in the UK. The first section examines health related worklessness within the UK social security system. Four key issues in current social policy debates about health related worklessness are then examined: ‘hidden unemployment’, ‘cultures of worklessness’, the ‘medicalisation of sickness absence’, and the ‘reserve army of labour’ thesis. The chapter then examines socio-economic inequalities in the employment consequences of ill health. The final section takes a more international approach by comparing health related worklessness by welfare state regime.

6.1 Health, worklessness, and the welfare state1

This section summarises the historical development of social policy in the UK with regard to health related worklessness, outlines the current social security system in relation to people who are workless on the grounds of ill health or disability, and then draws on political economy perspectives of the welfare state to analyse the changes.

6.1.1 The history of health related welfare

Historically in the UK and other advanced market economies, disability and chronic illness are associated with poverty and social exclusion (Acheson, 1998; Bartley and Lewis, 2002; Oliver and Barnes, 1998). This is largely because work is the main source of income for the majority of the population and people with disabilities and chronic illnesses have disproportionately low employment rates. Since 1945, UK government action in terms of changing this situation can be categorised into three distinct phases: ‘passive welfare’, ‘active welfare’ and what can be viewed as the emergence of ‘workfare’. This matches the broader development of advanced welfare states as previously outlined in Chapter 2.

(p.135) Passive welfare (1940s to 1990s)

The first phase of public policy towards the employment of people with a disability or chronic illness was framed by the Disabled Persons Employment Act of 1944 which set up supported employment programmes (such as Remploy), medical rehabilitation services, and the post-war employment quota (Figure 6.1). In the 1970s, these measures were supplemented with a number of specific health related out-of-work cash benefits, such as Invalidity Benefit in 1971 (renamed Incapacity Benefit in 1994). Cash benefits claimed on the basis of ill health were higher than those paid on the basis of unemployment in recognition of the long-term nature of ill health and the additional costs that it can involve. During the social security reforms of the 1980s and early 1990s, additional restrictions were placed on these cash benefits (e.g. the introduction of

                   Health related worklessness

Fig. 6.1 ‘Passive welfare’ for health related worklessness in the UK (1944 to 1991).

Source: Adapted from Bambra et al. (2005b).

(p.136) the ‘all work’ test in 1994). However, a radical shift of policy, fuelled by growing Treasury concerns about the costs of disability related benefits (HM Treasury, 1998), alongside pressure from disability campaign groups in relation to social exclusion (Barnes, 1991, 2002; Danieli and Wheeler, 2006), occurred in the mid-1990s. The Disability Discrimination Act of 1995 (and subsequent amendments) abolished the post-war disability employment quota in favour of a more rights based approach to the employment of disabled people (Floyd and Curtis, 2000; Oliver and Barnes, 1998). This Act saw the beginning of a distinction in social policy between people with a legally recognised disability and those with a chronic illness (Warren, 2005).

Active welfare (1990s to 2000s)

Although the UK welfare state has always contained a certain element of active welfare (for example Beveridge himself was an ‘activist’ and many of the initial post-war cash benefits, such as pensions, were only available to those who had previously paid social insurance contributions [Fulcher and Scott, 2003]), in more recent decades this element has become more prominent and far reaching. In the second phase of government action, people with a disability or long-term condition have been represented as a key group of working age benefit recipients and, as such, they have been the targets of a number of diverse active labour market interventions (HM Treasury, 2003). For example, the Disability Working Allowance, the New Deal for Disabled People, and the Access to Work programme (Figure 6.2). These interventions have generally tried to overcome the different barriers which people with a disability or chronic illness face when trying to enter employment, including: lack of experience or skills; uncertainty from employers; problems with physical access to work; and concerns over pay, hours and conditions (Gardiner, 1997; Goldstone and Meager, 2002). However, the majority of interventions have been supply-side focused, with little account taken for actual labour market demand. Participation by people in receipt of benefits has been on a voluntary basis (Bambra et al., 2005b; Bambra, 2006c). Houston and Lindsay (2010) note that ‘activation’ has also emerged as one of the dominant themes of reform across other European welfare states with benefits and services for people of working age becoming more focused on re-connecting recipients with the labour market and requiring recipients to be ‘active’ in seeking employment. Active labour market policies are outlined in more detail in Chapter 7.

Towards ‘workfare’ (2003 onwards)

Despite a rapid increase in these kinds of intervention since the 1990s, the employment rate for people with disabilities or a chronic illness has remained very low, at around 49%, compared with 81% for those without (Bambra and (p.137)

                   Health related worklessness

Fig. 6.2 ‘Active welfare’ for health related worklessness in the UK (1994 to 2002).

Source: Adapted from Bambra et al. (2005b).

(p.138) Smith, 2010). In the 2000s, there were still around 2.7 million people in receipt of health related benefits in the UK. This group has thus remained at the centre of the welfare reform agenda, with the benefits of (re)employment for health and well-being increasingly being emphasised in policy circles (Black, 2008). In 2003 Work Focused Interviews were a compulsory part of the Pathways to Work programme for new benefit recipients and most significantly, in 2008, Incapacity Benefit was replaced with the two-tiered Employment Support Allowance (see Box 6.1). This built on the previous reforms enacted in 1999, when health related claims became dependent on social insurance contributions and the Personal Capacity Test was introduced. However, the addition of such an element of conditionality for people in receipt of health related benefits is fairly new within the UK context and signals a break with the voluntary nature of previous participation in employment interventions. It is in some respects, therefore, the dawn of a third phase of policy towards the employment of people with a disability or chronic illness, and one which could be considered as a move towards making these recipients subject to a form of ‘workfare’ (Figure 6.3).

Workfare originated in the US, where it has a long history through such schemes as the Community Work and Training programme (1962–1967), the Work Incentive programme (1967), the Community Work Experience programme; and the Family Support Act (1988) (Burghes, 1987). Perhaps most well known are the Clinton-era reforms of 1996 when the Personal Responsibility and Work Opportunity Reconciliation Act introduced sanctions and benefit limits for millions of poor Americans, particularly lone mothers and their children: the so-called ‘99ers’ (as benefit receipt is limited to 99 weeks). Economically this Act has been considered a success, as welfare rolls halved in the first five years from 12.2 million in 1996 to 5.3 million in 2001. However, the social and economic costs for individuals are far more problematic, with only around 10–20% of those leaving welfare rolls actually getting work that pays above the federal poverty line. Similar reforms were announced in the UK in 2010, with compulsory work-for-benefit, as well as a ‘claimant contract’ with benefit sanctions, to be key aspects of the new Universal Working Age Benefit which will replace Jobseeker’s Allowance, Employment and Support Allowance and Income Support by 2015 (Department for Work and Pensions, 2010b). The term ‘workfare’ is used to refer to those welfare reforms that have linked participation in employment programmes to income maintenance. Workfare is thus the obligation on welfare recipients to ‘earn’ their benefit via participation in training as well as compulsory ‘work-for-benefit’ (Burghes, 1987).

The Employment and Support Allowance requires all but the most severely sick or disabled recipients to be work-ready by, for example, taking part in rehabilitation or retraining. All existing Incapacity Benefit recipients will (p.139)

                   Health related worklessness

Fig. 6.3 Towards ‘workfare’ for health related worklessness in the UK (2003 onwards).

Source: Updated from Bambra et al. (2005b) and Bambra (2006c).

(p.140) be re-evaluated and moved onto Employment and Support Allowance or Jobseeker’s Allowance. In addition, a new ‘fit note’ has replaced the old General Practitioner administered ‘sick note’ with the intention of keeping people in work once a health problem emerges to reduce long-term sickness absence and welfare rolls (Department for Work and Pensions, 2009). A Department for Work and Pensions report Building Bridges to Work explicitly stated that:

‘The old-style, passive, incapacity benefits have been replaced by the new, active Employment and Support Allowance’ in a bid to create a ‘something for something’ approach that aims to widen ‘the right to support and deepens the responsibility to take up this support: individuals have the responsibility to move towards and into work, in return they should get the help they need to do so’.Department for Work and Pensions (2010c: 7 & 21)

Employment and Support Allowance has several important features. Firstly, the new medical test is intended to tighten up eligibility and thereby cut the inflow of new recipients onto health related benefits. Indeed, the proportion of new applicants rejected by the new medical test has increased considerably from 39% under the old Incapacity Benefit regime tests, to 69% under the new regime (Department for Work and Pensions, 2009). Secondly, Employment and Support Allowance has introduced a new distinction between those recipients who might be expected to work (‘work related activity’ group) and those whose condition is so severe that there is relatively little prospect of them engaging in paid work (‘support’ group).

Under the new benefits regime, those deemed ‘fit for work’ will be immediately transferred onto the lower paying Jobseeker’s Allowance (Box 6.2), those deemed to be too ‘incapacitated’ for work will be placed on the Employment and Support Allowance with a ‘support’ premium and with no conditionality, whilst those considered ‘sick but able to work’ will be placed on Employment and Support Allowance with a ‘work related activity’ premium (see Box 6.1). (p.141) Failure to engage in compulsory ‘work related activity’ will result in a loss of this premium and placement on the Employment and Support Allowance basic rate. The reforms announced in 2010 mean that the ‘work related activity’ group will also see their entitlement to Employment and Support Allowance limited to one year. After a year they will have no right to benefits (not even Jobseeker’s Allowance) and will therefore become reliant on family support, charities or means-tested assistance (e.g. Income Support). It is expected that more than half of the 2.7 million Incapacity Benefit recipients will be placed into this group. Thus, for the great majority of recipients, Employment and Support Allowance is only a temporary benefit that will ‘activate the aspirations’ of recipients and encourage them to look for and take up paid work, and shift the ‘culture’ of incapacity benefits from ‘invalidity to employability’ (Department for Work and Pensions, 2008). Finally, in terms of delivery, Employment and Support Allowance will see an expansion in the contracting-out of work related activation to private and voluntary sector service providers on a ‘pay by results’ basis (i.e. the number of recipients moved into employment) (Freud, 2007). This mode of delivery is not unique to Employment and Support Allowance, but the large numbers involved means that contractors are delivering services to benefit recipients on an unprecedented scale.

There is little doubt that these reforms will succeed in reducing the levels of public expenditure spent on health related welfare benefits in the short-term, as those placed onto Jobseeker’s Allowance will face an immediate drop in income of about a third and the ‘work related activity’ group of Employment and Support Allowance recipients will see at least an equivalent reduction in their incomes after a year (Box 6.2). Many commentators, however, have questioned the likely success of these reforms in terms of actually increasing the employment rates of people with ill health or a disability. For example, in the context of economic recession, Fothergill (2010) has argued that shifting large number of recipients onto the Employment and Support Allowance via the Work Capability Assessment is a mistake. Many existing Incapacity Benefit recipients have poor health, poor skills, and have experienced extended periods out of the labour market, thus rendering their chances of finding employment in a highly competitive environment of low labour demand marginal. Further, Grover and Piggott (2010) have warned that Employment and Support Allowance is effectively a form of ‘social sorting’, separating people with a sickness or disability into subgroups of claimants dependent upon medicalised perceptions of the legitimacy of their condition and therefore of their entitlement to state support (see Section 6.2.3).

These welfare reforms are not unique to the UK and are fairly common in the welfare states of all advanced market democracies (Organisation for Economic (p.142) Cooperation and Development, 2009). For example, in Switzerland, reforms made in 2008 have meant that people on health related benefits are now obliged to participate in work related activities and there are clear sanctions for non-compliance. Similarly, in Luxembourg, people with partial work capacity are now obliged to enrol in training and reintegration measures. The Netherlands has reassessed all recipients under the age of 50 with significant reductions in benefit receipt. Sweden has also implemented less draconian reforms whereby long-term disability benefit recipients can engage in small amounts of paid work without benefit reductions, they can also engage in higher levels of work with only proportionate reductions to their benefits. However, if they cease work, they can resume their full disability benefit at any time without a new assessment (Organisation for Economic Cooperation and Development, 2009).

6.1.2 The political economy of health related welfare

Adding conditionality, in the form of compulsory involvement in active labour market programmes, is novel in terms of UK health related benefits. However, it is in keeping with the reform of other UK benefits (such as the reforms to unemployment benefit of the 1980s and 1990s) and changes to health related benefits elsewhere, such as in Australia, the US and other countries in the European Union (Stone, 1984; Organisation for Economic Cooperation and Development, 2003, 2009; Kemp 2006). These reforms are often presented as being initiated on the grounds of reintroducing recipients to the labour market or providing an incentive for people who are out of work to look for and return to work (Henning-Bjorn et al., 2004). However, the application of political economy theories provides some alternative explanations. Most notably in terms of labour discipline and moving those with ill health from the ‘deserving’ to the ‘undeserving’ poor.

Reasserting labour discipline

The reforms to health related welfare benefits can also be conceptualised as a way of reasserting labour discipline and instilling the work ethic. There are four salient aspects of the labour discipline thesis: Firstly, commentators such as Ginsburg argue that the social security benefits system disciplines the labour force by attaching conditions to benefits which ‘ensure that the intransigent worker cannot so easily turn to the welfare state for support’ (Ginsburg, 1979). This aspect of the labour discipline thesis is evident in the UK reforms as recipients of the Employment and Support Allowance will have to take part in employability schemes in order to receive full benefits. Secondly, following Piven and Cloward (1971/1993), the reforms can be seen as part of a wider welfare state retrenchment, as welfare provision acts as a means of ‘regulating (p.143) the poor’. Hence, provision tends to be expanded during times of political unrest and subsequently reduced once a measure of social peace has been restored. For example the civil unrest in the US in the 1960s was associated with a subsequent expansion of the welfare state which, once social order was restored, was followed up by a series of cut backs under the 1980s Reagan administration. Given that the UK has recently experienced a period of relative ‘peace’, it might be expected that welfare benefits would now be cut back. Thirdly, Katz (1986) argues that the stigma associated with benefit receipt also acts as a discipline upon the labour force, with dependency on state benefits considered not only a misfortune but a moral failure. The tiered approach of the new Employment and Support Allowance system to recipients may heighten this aspect of labour discipline, with those deemed ‘sick but able to work’ feeling particularly stigmatised. Finally, as Byrne’s work has shown (2005), the reforms to welfare provision of the last two decades in the UK and elsewhere (particularly the Clinton-era in the US) have not been about ending benefit dependency but about linking benefit receipt more closely to work. So for example, the Clinton administration’s Earned Income Tax Rebate and Earned Income Tax Credit as well as the Blair and Brown UK governments’ Working Family Tax Credit or Child Tax Credit have increased the income of working families substantially, but only whilst they are in-work—out-of-work cash benefits have not been increased and in some cases have been decreased (e.g. lone parents). Similarly, as has long been argued in regard to the political economy of the welfare state (see Gough, 1979), in-work benefits act as wage subsidies to low paying employers as they are funded via horizontal redistribution within the working class rather than vertically via income redistribution and corporate taxes (Byrne, 2005: 156). The welfare reforms can thus be seen as the somewhat logical extension of the use of the benefits system to assert the work ethic. The reforms similarly reinforce divisions of who is (working poor) and who is not (non-working poor) deserving of state support.

No longer deserving

The separation of health based claims into two distinct categories is, on the one hand, a logical consequence of the philosophy of ‘work for those who can, welfare for those who cannot’ approach to welfare reform (Blair, 2002), and an acknowledgment that previous, more passive approaches have often exacerbated the labour market exclusion experienced by people with a disability or chronic illness. However, on the other hand, the division into two levels of benefits is inevitably tied into notions of the ‘deserving’ and ‘undeserving’ poor (Katz, 1989; van Orschot, 2006). Health related cash benefits are amongst the last in the UK system to be the subject of extensive reform and, until (p.144) recently, did not attract as much popular stigma as other types of benefits (most notably lone parent benefits). This is also the case in other countries, where people in receipt of benefits due to ill health or disability have been viewed and treated as more ‘deserving’ or morally worthy than those in receipt of other types of benefit (Stone, 1986; van Orschot, 2006). Indeed, as Stone argued in ‘The Disabled State’ (1986), in many Western countries, disability was for a long time considered to be a special administrative category in the welfare state and one which came with distinctive entitlements in the form of social aid and exemptions from certain obligations of citizenship, such as the duty to work (Stone, 1986: 4). Drawing on Stone (1986), welfare reform in this area can thus be seen as a clear move away from the more accommodating perspective of the period of ‘passive welfare’, and the beginning of a potentially disturbing political discourse which dictates that certain types of illness or disability are less deserving of unconditional public support than others.

People with a disability or chronic illness are thus variously categorised and re-categorised within the ‘deserving’ and ‘undeserving’ poor dichotomy. The relations of production which arose from capitalist industrialisation established a discourse of ‘able-bodiedness’ which excluded the impaired and the chronically ill from the workplace and the discourse of employability in general (Oliver, 1990; Stone, 1986; Finkelstein, 1980; Gleeson, 1991). However this has been renegotiated at various times and on different terms. For example, the context of the Second World War forced employers to employ groups who were not traditionally regarded as employable, such as disabled people. Disability and ill health were also transformed by the experience of the war as perceptions of ‘disability’ shifted because impairment was now more visible, prevalent and also more socially acceptable as these impairments were being acquired by those traditionally cast as those most worthy of employment: young adult males who had served in the armed forces (Stone, 1986). The Disabled Persons Employment Act of 1944, which followed the recommendations of the Tomlinson Committee on the rehabilitation of disabled people, thus established the long-term sick and disabled as the ‘deserving’ poor. It did not attempt to promote wider equality in the labour market where the social contract was to provide full employment for able-bodied male workers (see Chapter 1).

What is clear in the welfare reforms implemented since the 1990s has been the renegotiation of this ‘deserving’ and ‘undeserving’ dichotomy. This was influenced by a number of factors. Firstly, from the late 1980s onwards, disabled people mounted increasingly visible and successful campaigns to gain equal rights legislation (as had been passed in the 1970s with regard to sexual (p.145) and racial equality). This influenced the enactment of the 1995 Disability Discrimination Act which is similar in remit to those in the US, Australia and Sweden (Bambra and Pope, 2007). Since 2006, all EU member states are obliged to adopt similar legislation (Organisation for Economic Cooperation and Development, 2009). The Disability Discrimination Act, whilst limited in many ways (for an overview see Roulstone and Warren, 2006), was an important landmark as the state had conceded that disabled people faced widespread discrimination and disadvantage in the labour market, workplace and wider society (Box 6.3). The Disability Discrimination Act is also significant, as its very existence clearly differentiates ‘disability’ from ‘sickness’ (e.g. long-term health conditions which are limiting but not disabling).

This group who could be termed the ‘sick but not disabled’ are arguably now more marginalised as they have no recourse to anti-discrimination legislation and have thus been moved out of the ‘deserving’ and into the ‘undeserving’ poor. The diminished status of the ‘sick but not disabled’ who are workless has implications regarding citizenship. It means that their citizenship is also ‘lesser’ than that of those classified as ‘disabled’ under the Disability Discrimination Act. Their lack of any special legislative protection means they are potentially subject to greater surveillance by the state via the welfare system, which is able to make receipt of benefits increasingly conditional. This conditionality involves the collusion of certain parts of the medical profession with, for example, tests of the legitimacy of the health claims of Incapacity Benefit recipients administered by doctors employed by private sector healthcare groups on behalf of the Department for Work and Pensions—an example of Finkelstein’s (1980) ‘administrative model of disability’. The construction of disability has long been an important feature of the welfare state as it places fewer obligations on those deemed ‘disabled’ (Stone, 1986). As Stone comments, the state determines what injuries, diseases, and incapacities those defined as non-disabled have to endure as part of their normal working lives (Stone, 1986: 4). In this context, it is worth considering that this deserving/undeserving dichotomy and the redrawing of the lines around what is and what is not incapacity may well magnify stigma attached to claims based on ‘hidden’ (i.e. mental illness) as opposed to ‘visible’ illnesses (i.e. physical illness). Arguably everyone who is not in employment and dependent upon the state for their subsistence is subject to increased surveillance and subsequently has diminished citizenship. However the long-term ‘sick but not disabled’ are in a particularly disadvantageous position, as they are without the ‘rights’ attributed to ‘disability’, and are statistically far less likely to return to the labour market than the unemployed. Consequently they endure state surveillance for longer whilst also being subjected to medical administration. (p.146)

6.2 Key debates about health related worklessness

Given the increased rates of sickness and disability related social security claims in the UK and other European countries, worklessness is now much discussed in academic, policy and media spheres (for examples, see Crisp, 2008; Webster, 2006; Ritchie et al., 2005). Many issues have therefore emerged (p.147) and chief amongst these are: concerns as to whether ill health related worklessness is actually ‘hidden unemployment’ (Beatty et al., 2000); whether inter-generational and structural worklessness over the last 30 years has created ‘cultures of worklessness’ (Fletcher, 2007); whether the medicalisation of sickness absence and the legitimacy of the ‘sick role’ is part of the problem (Black, 2008); and whether those out of work due to illness actually form a ‘reserve army of labour’ (Russell, 2002). This section explores these issues in more detail.

6.2.1 Hidden illness and hidden unemployment

The reforms to health related benefits outlined in Section 6.1.1 need to be understood in the context of political debates about the relationship between unemployment and health (Bambra, 2008; Bambra and Smith, 2010) and the relationship between benefit receipt, health and employment (Bambra and Norman, 2006). Although in order to qualify for most health related benefits across the OECD, medical certification by a general practitioner or benefits system doctor is required, welfare systems have long been criticised as providing a means of avoiding work, and thereby obscuring true unemployment levels (Beatty et al. 1997, 2000, 2007; Fieldhouse and Hollywood, 1999). Certainly, the rapid increase in health related benefit claims across the OECD in the 1980s and 1990s coincided with similar decreases in the numbers in receipt of unemployment benefits. This in itself is potentially indicative of substitution between the two types of benefit schemes, perhaps linked to the earlier reform of unemployment benefits (Organisation for Economic Cooperation and Development, 2009).

In the UK, this perception is also fuelled by the fact that the geographical distribution of incapacity related benefit claims in the UK is skewed towards the de-industrialised areas of the North East of England, the West of Scotland and South Wales: the spatial patterning of health related worklessness thus reflects ‘the loss of jobs in manufacturing and mining, which has not only been large overall, but has also clearly been concentrated in the cities and coalfields’ (Webster, 2000: 124). This is shown clearly in the map of England and Wales (Figure 6.4) and Table 6.2, which lists the ‘best’ and ‘worst’ 10 local authorities in England and Wales in terms of Incapacity Benefit standardised ratios. The best local authorities are mainly semi-rural non-deprived commuter and ‘stock-broker’ belt areas in the affluent South East region. The worst local authorities comprise the old industrial areas. These communities lost their main sources of employment, such as the coal, steel and shipping industries, in the rapid restructuring of the 1980s and 1990s when manufacturing jobs were lost at a rate of up to 1,000 per week in industrial centres such as Sheffield, (p.148)

                   Health related worklessness

Fig. 6.4 Standardised illness ratios of Incapacity Benefit claims by local authority, England and Wales.

Reproduced from Norman and Bambra (2007) with permission from the publishers John Wiley and Sons.

England (Fletcher, 2007). There was not enough in the way of new local employment to replace these large industries, and the service sector jobs that did emerge did not match the skills of the existing workforce. In the 1980s and 1990s, Conservative governments actively encouraged a transition to sickness benefits in these communities as a way of reducing the numbers on unemployment benefits and thereby keeping the politically sensitive unemployment rate artificially low (Adams 1999; Bivand 2002). Further, the higher value of Incapacity Benefit in comparison to unemployment benefit may have acted as (p.149)

Table 6.2 Local Authorities in England and Wales with the highest and lowest standardised ratios of Incapacity Benefit recipients



Local Authority


Local Authority


Merthyr Tydfil





North East

Surrey Heath

South East

Blaenau Gwent



South East

Neath Port Talbot



South East

Rhondda, Cynon, Taff


South Bucks

South East


North West

Windsor & Maidenhead

South East


North West


South East



South Oxfordshire

South East


North West




North East

Vale of White Horse

South East

Source: Reproduced from Norman and Bambra (2007) with permission from the publishers John Wiley and Sons.

a financial incentive for individual recipients. It has also been argued that general practitioners in deprived areas may have exacerbated the above trend in recognising that, manual workers in particular would struggle to find employment in the newly de-industrialised areas (Legard et al., 2002; Ritchie et al., 1993).

Beatty and colleagues (2000) have therefore argued that regional differences in employment rates conceal what can be termed ‘hidden unemployment’. This concentration of ‘hidden unemployment’ in the former industrial areas suggests that some regional economies have not fully recovered from the fallout of de-industrialisation, a conclusion also reached by a number of other researchers (see Turok and Edge, 1999; Webster, 2006; Theodore, 2007). Beatty and colleagues (2007) estimate the ‘real’ level of unemployment in the UK in 2007 was 2.6 million, compared with 1.6 million in the International Labour Office definition of unemployment and only 0.9 million claiming Jobseeker’s Allowance. This is based on a estimate that around 40% of incapacity related benefit recipients could reasonably be expected to have been in work in a genuinely fully employed economy, corresponding to 560,000 men and 450,000 women. However, it is important to point out that the concept of ‘hidden unemployment’ does not assume any fraudulent claims of sickness and ill health. Incapacity Benefit receipt requires medical assessment and as individual level evidence from recent cohort studies shows, medically certified sickness absence clearly reflects actual morbidity and mortality (Marmot et al., 1995, (p.150) Kivimäki et al., 2003c, Vahtera et al., 2004). Population level studies have also found higher associations between Incapacity Benefit claims in England and Wales and morbidity (r=0.98 p〈0.01, 2001 census limiting long term illness; r=0.97 p〈0.01, 2001 census not good health) and mortality (r=0.80 p〈0.01, 2001 Vital Statistics) than unemployment (r=0.72 p〈0.01, 2001 census) (Bambra and Norman, 2006; Norman and Bambra, 2007).

Beatty and colleagues (2000) therefore also refer to the term ‘hidden sickness’. ‘Hidden sickness’ refers to those in employment suffering from some form of ill health or disability. Although many such people would be sufficiently sick to be eligible for benefits, they are at the same time able to perform some or all of the duties required in their job, in some cases with modifications agreed with their employer to accommodate their incapacity (such as working part-time or avoiding heavy lifting). Beatty and colleagues argue that in a tight local labour market at full employment, many people with some form of incapacity who are able to do some types or amounts of work are therefore likely to be in employment. In a slack local labour market experiencing high levels of unemployment, many such people will instead claim incapacity related benefits. Consequently, people with ill health remain towards the end of the ‘jobs queue’ (Berthoud, 2008). The dual concepts of hidden unemployment and hidden sickness together predict that in tight labour markets there will be little hidden unemployment and a lot of hidden sickness, while in slack labour markets there will be little hidden sickness and a lot of hidden unemployment (Beatty et al., 2000). This is in keeping with the ‘reserve army of labour’ thesis which is examined in Section 6.2.4.

6.2.2 Cultures of worklessness

The complex economic, social and geographical connections between health related worklessness and unemployment have fuelled the view that health related welfare claims represent a form of ‘welfare scrounging’ and act as a disincentive to work (Bambra and Norman, 2006). Such views are not limited to the UK (Organisation for Economic Cooperation and Development, 2003), nor are they particularly new; American Social Security Disability Insurance, for example, was subject to similar debate and was subsequently reformed under the Reagan administration in the early 1980s (Stone, 1986). In the UK, politicians and the media often talk about a ‘dependency culture’, ‘habits of worklessness’, or ‘cultures of worklessness’, particularly in relation to areas of high incapacity benefit receipt. This is despite evidence that a substantial proportion of those in receipt of benefits want to return to work and would do so if they were given appropriate support (Beatty and Fothergill, 2005; Joyce et al., 2010a; Smith et al., 2010). There is little evidence of a lower work ethic (p.151) amongst workless people (Gallie, 2004). Workless individuals face multiple barriers to employment, such as a lack of relevant job skills and experience as well as problems accessing the work environment (often relating to transport and carer costs), and stigma surrounding ill health and work ability from employers (Danziger et al., 2002). Indeed, poor health and disability make it difficult for some individuals to secure jobs in a competitive labour market in which employers demand flexibility (Houston and Lindsay, 2010). Living in areas of high worklessness can also entail stigma, with whole communities stereotyped as feckless and work shy (Fletcher, 2007). These barriers mean that helping individuals move from ‘welfare and into work’ may not easily be addressed by single, linear interventions (Gardiner, 1997; Bambra et al., 2005b; Ritchie et al., 2005). This is particularly likely to be the case where changes in local economies have restricted employment options.

A particularly emotive notion, ‘worklessness’ has negative connotations, with ‘cultures of worklessness’ implying idleness and fault on the part of the workless individual and their communities, thus implying that such people and places are to blame for their own worklessness and poverty. Grover and Piggott (2007: 735) remark that there is a moralising discourse through which the receipt of incapacity benefit is constructed as being indicative of a ‘dependency culture’ of sick and disabled people who are encouraged into idleness by the structure of the benefits that they receive. Grover comments that the public, policy and political discourses surrounding worklessness construct ‘workless people as those who ‘won’t work’, rather than those people for whom there are few jobs to apply for, who face barriers to work, including various and multiple forms of discrimination’ (2007: 536). ‘Worklessness’ is thus a term that combines together those unable to work through age, illness or disability, alongside those allegedly unwilling to work through lack of aspiration or cultural influences (Welshman, 2006). This echoes the ‘undeserving’ and ‘deserving’ poor, implying that the workless are ‘undeserving’ if they do not at least seek paid employment, regardless of the quality and calibre of that employment. On the other hand, the ‘deserving’ poor are those who are actively seeking work and who are keen to make a contribution to society in this way (as discussed in Section 6.1.2).

The creation of a ‘culture of worklessness’ and the association of this with the attitudes and behaviour of marginalised groups owes much to the ‘culture of poverty’ debates that emerged in the US in the late 1960s in which cultural patterns (family structure, interpersonal relations, value systems, sense of community and spending patterns) were seen as inter-generationally transmitted to reinforce a recurring cycle of poverty (Fletcher, 2007). This idea was taken up in the UK in the 1970s by Keith Joseph with his promotion of the idea of a ‘cycle of (p.152) deprivation’ (Fletcher, 2007). In the 1980s, other US theorists such as Charles Murray (1990) used ideas of inter-generational cultures to claim that they could identify an ‘underclass’; a culturally distinct and deprived minority that included both the delinquent and the welfare dependent. Illegitimacy, violent crime and non-participation in the labour market were deemed to be key indicators and socially acceptable norms of this ‘underclass’ (Fletcher, 2007). The creation and existence of the ‘underclass’ was the fault of an overly generous welfare system, not employers, the macro-economic environment or the wider system of economic inequality. These views have been counteracted by those such as Byrne (2005) who talk about the long term social exclusion of the poor and of deprived communities as a result of government action (or, more usually inaction).

This ‘culture of worklessness’ approach suggests that worklessness and benefit receipt can only be understood in terms of the ‘faulty’ attitudes and behaviours of deprived families and communities: ‘In some areas a culture of worklessness or poverty of aspirations has developed, locking people into cycles of worklessness’ (HM Treasury and Department for Work and Pensions, 2003: 46). This enlarges the victim blaming discourse around ill health, poverty and welfare receipt from one which focuses on the individual to one that stigmatises entire (working class) communities and ways of life. Such attitudes have a long history in the UK and other European countries, dating back to early twentieth century views of the morally defective nature of slum dwellers (Fletcher, 2007). They have also underpinned entire policy interventions, such as the Working Neighbourhoods programmes in the UK (Fletcher, 2007). Policy debates about Incapacity Benefit and worklessness are thus shaped as much by ideological and political factors as by broader economic trends.

6.2.3 The medicalisation of sickness and sickness absence

‘Medicalisation’ first came to prominence in the 1970s and it is a term used to describe how medicine extends its power by colonising areas of social life. Conrad (1992) defines medicalisation as:

‘The process by which non-medical problems become treated and defined as medical problems usually in terms of illnesses or disorders’.

Conrad (1992: 209)

Conrad traces the roots of the medicalisation thesis to Parsons’ influential description of the ‘sick role’ in which sickness is identified as a social role which has rights and responsibilities (Parsons, 1951[1991]). In terms of rights, a sick person is temporarily exempt from ‘normal’ social roles (such as paid work) and the more severe the sickness, the greater the exemption. Sickness also entails an absence of blame and the sick person is not held responsible for (p.153) their condition. Subsequently, the sick person has a right to treatment and support. However, the exemption from normal responsibilities is temporary and conditional upon trying to leave the state of sickness and regain health— to ‘get well’. The sick person therefore also has an obligation to seek professional medical help and to cooperate in the recovery process.

Parsons considers the sick role to be a social threat as ‘the sick’ are relieved of their usual duties within capitalist production (i.e. to work, or to care for the family). Sickness can be used to evade social responsibility. Medical professionals are central to the process of assigning and legitimising the social status accorded to illness. They act as ‘gatekeepers’ against illness as social deviance and they provide a form of social regulation. The medicalisation thesis developed alongside the anti-psychiatry movement whose exponents, such as Szasz (1964) Laing (1967) and Cooper (1968), criticised medical professionals for acting as agents of social control. The medicalisation thesis thus ‘draws attention to the fact that medicine operates as a powerful institution of social control’ (Nettleton, 1995: 27). Freidson (1970) was one of the first researchers to attempt to theorise how medicine established and maintains its social power. He argued that state patronage established orthodox medicine in a dominant position. This cemented a particular form of occupational control over patients and other practitioners within the health sector. However in order to retain this position, medicine has to engage in a continuing political struggle to retain its dominance, in both the healthcare division of labour and its control over the direction of the profession and its work.

Extension of medical power to spheres of life previously beyond it (childbirth is a prominent example), is also a crucial way in which medicine maintains and extends its dominance. Medicine is thus part of a wider bureaucratisation of social life in advanced capitalist economies which disempowers individuals in favour of experts and professionals (Zola, 1972). Medicalisation is a process which strips away the resources and abilities of individuals and communities to cope with their own problems by replacing them with a hegemony of disabling professionals (Illich, 1976 [1995]). Sickness absence and health related welfare benefits are a strong example of the process of medicalisation as doctors are a central part of the administrative and legal sides of the welfare system. They are responsible for assessing the entitlement and legitimacy of all applications for sickness and disability benefits (Finkelstein, 1980). Medicine therefore acts as a gatekeeper to accessing health related welfare benefits. For example, absence from the workplace due to sickness either on a temporary or on a long-term basis is usually regarded as legitimate. However, this legitimacy is dependent upon validation by a medical practitioner who also has the ability to revalidate the legitimacy of such claims or to withdraw their validation.

(p.154) This gatekeeper role, whilst clearly disempowering for individual workers, has also recently been criticised by government and by employers as effectively disempowering them in their ability to prevent sickness absence and enhance return to work (Organisation for Economic Cooperation and Development, 2009). As discussed in Section 6.2.1, falls in unemployment benefit receipt have to a greater or lesser extent been matched by increases in health related benefit receipt. This has led to the view, as expressed by a high level OECD report (2009), that a predominantly labour market issue has become a medical one:

‘The purpose of publicly-funded disability benefits [has shifted], from providing a safety net for persons who are unable to secure employment because their ability to compete for work is weakened (i.e. a labour market issue), to compensation for permanent loss of functioning due to injury or sickness (i.e. a medical issue)’.

Organisation for Economic Cooperation and Development (2009: 18)

This application of the medicalisation thesis contends that the use of medical criteria to assess whether someone is fit for work results in significant numbers of people with partial work capacity being medically deemed incapacitated for work, often on a permanent basis:

‘Whereby their formal obligation to seek employment ceases and, in most benefit systems, they are also indirectly compelled to remain inactive and assert they are incapable of work in order to continue to receive payments’.

Organisation for Economic Cooperation and Development, (2009: 18)

The medicalisation of worklessness has thus allowed the medical model of disability and sickness, whereby people with a health condition or disability are ‘incapacitated’ and incapable of participating in the workforce, to dominate this area of labour market policy. It is argued that medicalisation has thus facilitated the entrenchment of a ‘benefit culture’ (Section 6.2.2) and acted to undermine attempts to reform health related welfare benefits (Organisation for Economic Cooperation and Development, 2009).

Policymakers across advanced market economies have attempted to undermine the historical dominance of the medical model with regard to health related welfare. In the UK, for example, the ‘sick note’ which was traditionally used to certify sickness absence operated on a zero-sum basis: an individual was either too sick to work or well enough to work. This was replaced, after much government effort, in 2010 with a ‘fit note’ which is intended to assess fitness for work, as opposed to sickness. The fit note adds the option of being partially fit for work if certain issues are taken into account including a phased return to work, altered hours, amended duties and workplace adaptations. The intention of the fit note is to reduce the number of people on short-term sickness absence who then lose their employment and become long-term (p.155) benefit recipients. The fit note is also intended to address concerns that general practitioners were too close to their patients and too keen to sign people off—‘on the sick’ (particularly in areas or times of high unemployment) (Organisation for Economic Cooperation and Development, 2009). Similar reforms have occurred in Australia and Denmark. In Australia, those who are out-of-work due to ill health are subject to a ‘job capacity assessment’ that determines their work ability. Since 1998, Denmark has operated a scheme of subsidised jobs (‘flexjobs’), this offers a permanent wage subsidy to employers of 50% to 65% of the total salary for the employment of people with a permanent reduction in work ability due to illness or disability. The scheme also includes reduced working hours, adapted working conditions, or restricted job demands. Employment in flexjobs has increased dramatically since the introduction of the scheme: from 6,700 in 1999 to 40, 600 in 2006 (Whitehead et al., 2009). These changes have to be understood in relation to the wider shifts in welfare policy for those with a health condition or disability from a passive (incapacity) model to a more active (work capability), and ultimately, towards a workfare model (Section 6.1.1).

6.2.4 Sickness, disability, and the reserve army of labour

The ‘reserve army of labour’ thesis was developed by Marx who describes it as a holding pool, a reservoir of labour which can be accessed by capital at very short notice. It is cheap, highly convenient and also economically efficient as workers are not being retained and paid for by employers during periods of low market demand. The existence of a reserve army also regulates the wages of those in employment as it undermines their wage bargaining capacity:

‘Taking them as a whole, the general movements of wages are exclusively regulated by the expansion and contraction of the industrial reserve army’ and ‘the industrial reserve army, during the periods of stagnation and average prosperity, weighs down the active army of workers; during periods of over-production and feverish activity, it puts a curb on their pretensions’.

Marx (1867 [1976]: 790 & 792)

Marx argues that the reserve army of labour—or the surplus population— always has three forms: the floating, the latent and the stagnant. The floating part refers to the temporarily unemployed, the latent part consists of that segment of the population not yet fully integrated into capitalist production—for example, parts of the rural population in the nineteeth century—and the stagnant part which consists of marginalised people with extremely irregular employment who dwell in the sphere of pauperism. Applying Marx’s analysis to the post-war period, Ginsburg argues that a central function of the welfare state is the production and maintenance of the industrial ‘reserve army of labour’ (p.156) which depresses the market price of labour. The state, by providing social security and other welfare services for the ‘surplus population’, ensures the daily and generational reproduction of labour and collectivises the costs (Gough, 1979; Ginsburg, 1992).

In the 1970s, the reserve army of labour thesis was applied by feminist and anti-racist writers to explain the role of women, ethnic minority and immigrant workers within the labour market and the welfare state. These newer applications of the ‘reserve army of labour’ thesis also influenced writers from the disability rights movement such as Finkelstein (1980) or Oliver (1990) who then applied the idea to the labour market relationships of people with a disability. There is certainly evidence from the US to show that disabled people experience proportionally larger gains in employment during economic booms, and suffer proportionally greater losses during times of contraction than those without a disability (Yelin and Katz, 1994: 36) with disability benefit claims also rising (Russell, 2002). There are further issues. In Marx’s original typology of the ‘reserve army of labour’, disabled people and those with ill health were placed in the group least likely to become employed: the ‘stagnant’ reserve army of labour. The passive welfarism of the immediate post-war period incorporated this view (see Section 6.1.1). However, the welfare reforms of the 1990s, the activation agenda and the emergence of workfare in some countries in relation to health related worklessness, have placed more people with a health problem or disability into the ‘active’ (floating) pool of the reserve army of labour. Enlarging the available pool of labour in this way benefits capital as having more people competing for work keeps wages down (Russell, 2002). Beatty and colleagues’ (2000) theories of hidden unemployment and hidden sickness are also relevant in this regard (see Section 6.2.1).

The ‘reserve army of labour’ thesis has been subjected to a number of criticisms. In relation to health related worklessness, as Grover and Piggott (2005) have argued, it is not the case that all disabled or chronically ill people are part of the ‘reserve army of labour’ as at least a third of those of working age are in some form of employment. Consequently the idea that all of the long-term sick and disabled, or all women or all ethnic minority and immigrant workers, constitute a ‘reserve army of labour’ is problematic, and ‘membership’ is highly stratified by socio-economic class, and local labour market conditions, with low skill levels a clear characteristic of membership of any ‘reserve army of labour’. It can also be argued that in some particularly deprived areas, structural unemployment levels and long-term health related benefit receipt are so high and so intransigent that such groups are far removed from the labour market and thus no longer constitute a ‘reserve army of labour’ so much as a dislocated and socially excluded ‘underclass’ (see Section 6.2.2). Another perspective (p.157) is that the high levels of part-time work amongst women, immigrants and those with a disability or chronic illness, suggest that whilst they may not constitute a ‘reserve army of labour’ in a zero-sum (unemployed-employed) sense, they are under-employed and can thus be fully employed in times of labour market expansion and then under-employed once more in times of contraction.

6.3 Socio-economic inequalities in health related worklessness

Ill health increases the likelihood of long-term worklessness. For example, a study of health related worklessness in the UK using national household survey data found that the employment rates of people with limiting long-term illness (LLTI) or disability were 45.9% compared to 82.4% of those without an illness or disability (Pope and Bambra, 2005). This varies by gender with women with an LLTI having a lower employment rate than men with an LLTI: in the UK, 58.9% of men with an LLTI were employed in 2005 compared to 49.9% of women. Differences in employment rates with respect to health and gender are also present in other advanced market democracies. For example, in 2005, the employment rates of men with a LLTI in Canada were 62.7% compared to 86.4% for those without, in Norway 70.6% to 93.2% and in Sweden 62.6% to 93.3% (Whitehead et al., 2009). The employment rates of women with a LLTI in 2005 were even lower: in Canada they were 53.6% for those with LLTI compared to 74.7% for those without, in Norway 64.3% to 88.6% and in Sweden 64.9% to 88.4% (Whitehead et al., 2009). However, health related worklessness is also unevenly socio-economically distributed. A comprehensive comparative study by Whitehead and colleagues (2009) found that there were significant educational inequalities in the employment rates of people with LLTI (Table 6.3). In the UK, the study found that, in 2005, employment rates of men with a low education and a LLTI were 65.6% less than healthy men with a low education, 58.7% less than highly educated men with LLTI and 68.1% lower than healthy, highly educated men. These patterns were even starker for UK women: those with a low education and LLTI had employment rates of 71.2% less than healthy women with a low education, 72.6% less than highly educated women with LLTI and 79.4% lower than healthy, highly educated women. Internationally, these patterns were repeated to a greater or lesser extent (Whitehead et al., 2009) with the employment gaps between healthy highly educated men and low educated men with LLTI ranging from 30.9% in Norway to 68.1% in the UK, and between healthy highly educated women and low educated women with LLTI ranging from 57.7% in Sweden to 79.4% in the UK. (p.158)

Table 6.3 Differences in the employment rates of working age people (aged 25–59) with and without limiting long-term illness (LLTI) by educational status in four countries (1980s compared to 2000s)

Rate Differences (%) by educational and health status














Low education LLTI v Low education healthy









Low education LLTI v High education LLTI









Low education LLTI v High education healthy










Low education LLTI v Low education healthy









Low education LLTI v High education LLTI









Low education LLTI v High education healthy









(a) Data from Labour Force Survey 1984–1986 and 2004–2006.

(b) Data from Census 1986 and 2001.

(c) Data from Survey of Living Conditions 19801983 and 20022005.

(d) Data from Survey of Living Conditions 19821984 and 20032005.

Source: Author calculations of rate differences using data presented in Tables 5.5 to 5.9 in Whitehead et al. (2009).

(p.159) The Whitehead and colleagues (2009) study also found that the employment situation for low educated people with LLTI had significantly worsened since the 1980s in all the countries studied. In the early 1980s, the employment rates of low educated healthy men in the UK were 82.2% compared to 94.6% for highly educated healthy men, a gap of 13.1%. By the mid-2000s this situation had improved with the gap closing to 7.2% (Whitehead et al., 2009). Over the same period, the employment gap between healthy high and low educated women in the UK increased slightly from 23.9% to 28.5%. However, for low educated men and women with LLTI, the employment gap between them and the rest of the working age population, the healthy and unhealthy, increased massively. In the early 1980s, the gap between men with a low education and LLTI compared to healthy low educated men was 51.6%, by the mid 2000s this had increased to 65.6%. The gap with highly educated men with LLTI increased from 48.5% to 58.7% and the gap with healthy highly educated men increased from 58.0% to 68.1%. For low educated women in the UK with LLTI, the labour market was even more unfavourable with their employment rates falling from 26.6% in the early 1980s to 18.1% in the mid-2000s. This represents an employment gap in the mid-2000s of 71.2% between them and healthy low educated women, compared to 54.0% in the 1980s. The employment gap between low educated women with an LLTI and highly educated women with an LLTI increased from 51.7% to 72.6% and the gap between low educated women with an LLTI and healthy highly educated women rose from 65.0% to 79.4% in the same period. These findings were similar in the other countries studied by Whitehead and colleagues (2009), although the magnitudes of educational inequalities in employment varied. Structural worklessness is of increasing importance to socio-economic inequalities in health.

6.4 Welfare state regimes and health related worklessness

The employment rates of people with an illness or disability vary by welfare state regime. This is demonstrated in Table 6.4. Health related worklessness is lowest in the Scandinavian welfare states, where the worklessness rates of people with a LLTI is 30.3% in Iceland, 33.1% in Sweden, 41.6% in Finland and Denmark, and 42.4% in Norway with a welfare state regime average of 37.8% (van der Wel et al., 2010). Health related worklessness is highest in the Anglo-Saxon countries of the UK and Ireland where 49.9% and 64.3% respectively of people with LLTI are workless. The Bismarckian (Luxembourg 40.6%, Austria 42.2%, France 45.8%, Belgium 59.0%, Netherlands 50.8%) and Southern (Cyprus 41.9%, Italy 51.3%, Portugal 48.2%, Spain 58.3%, Greece 62.2%) (p.160)

Table 6.4 Rates of worklessness in the working age population (aged 25–59) in Western Europe by health status and welfare state regime

Welfare State Regime

Worklessness rate in healthy working age population (%)

Worklessness rate in working age population with limiting long-term illness (%)













Source: Un-weighted welfare state regime averages calculated by the author using data from the European Union Survey of Income and Living Conditions as presented by van der Wel et al. (2010).

welfare states hold intermediate positions with average health related worklessness rates of 47.7% and 52.4% respectively. There are also significant cross-national differences in terms of the magnitude of socio-economic inequalities in the employment consequences of ill health. This is evident in Whitehead and colleagues’ (2009) research which found that educational inequalities in worklessness were higher in the UK (and to a lesser extent in Canada) than in the Scandinavian countries (as demonstrated in Table 6.3). This issue has also been explored by van der Wel and colleagues (2010) in a comparative study of inequalities in the employment consequences of sickness by welfare state regime. In a multi-level analysis of 25 countries using data from the European Union Survey of Income and Living Conditions, van der Wel and colleagues compared labour force participation by educational status and health. They found that in all countries, people with health problems have lower employment rates than those who are healthy and that worklessness rates are particularly high amongst people who have both a health problem and a low education. However, the study found that the employment rates of those with a health problem and a low education are higher amongst those welfare states—the Social Democratic ones—that invest in active labour market policies, have higher levels of income equality and provide more generous welfare benefits (van der Wel et al., 2010).

These differences by welfare state regime in health related worklessness and inequalities in worklessness may also be linked to the different ways in which sickness absence (both short-term and long-term) is treated in different welfare states. This issue has long been of importance in comparative social policy. The level of sickness absence decommodification was one of the central aspects of Esping-Andersen’s Three Worlds of Welfare typology (1990) in which welfare state regimes were first conceptualised (see Chapter 2). The Social Democratic welfare states had the highest level of decommodification, particularly in terms (p.161) of replacement rates, and the Liberal welfare states had the lowest (Esping-Andersen, 1990; Bambra, 2006b). In 2003, the OECD published a more comprehensive taxonomy of welfare states which clustered them in terms of two key aspects of their disability and sickness absence policies: compensation (including benefit replacement rates, eligibility requirements, length of disability, population coverage) and integration (focusing on vocational rehabilitation and employment measures such as work incentives or employer obligations) (Organisation for Economic Cooperation and Development, 2003). This produced a five-fold taxonomy of disability policy clusters: Anglo-American (Canada, US, UK); Scandinavian (Norway, Sweden, Denmark); Germanic (Austria and Germany); Romanic (France, Italy, Portugal, Poland, Spain, Belgium); and a mixed cluster (Netherlands, Australia, Switzerland). The Anglo-American model is characterised by strict medical requirements, relatively low replacement rates, substantial employer responsibilities, weak vocational rehabilitation programmes, and significant return to work incentives (Organisation for Economic Cooperation and Development, 2003: 129). The Scandinavian model is characterised by full population coverage, generous benefit levels, strict medical assessment, a strong focus on employment subsidies and on extensive vocational rehabilitation. The Germanic model offers only labour force coverage; medium benefit levels, work incapacity limited to own occupation, and has a strong rehabilitation focus. The Romanic model has a weak rehabilitation programme, work incapacity limited to own occupation, a strong focus on employment subsidies, and strict medical criteria. Countries in the ‘mixed’ model have full population coverage (means-testing in Australia), significant employer responsibilities, substantial focus on sheltered employment and varying benefit levels (Organisation for Economic Cooperation and Development, 2003: 130). In terms of the compensation or integration dichotomy, most countries still offer a mix of both of these approaches with Denmark closest to a fully integrationist approach (Organisation for Economic Cooperation and Development, 2003: 129).

6.5 Conclusion

In this chapter, I have examined health related worklessness from both a public health and a social policy perspective. With regard to social policy, I have overviewed the historical relationship between health related worklessness and the social security system, with a particular focus on the UK. I have argued that there have been three clear phases in welfare state development with regard to the treatment of people with a disability or health condition, and that recent reforms in the UK and across other advanced market democracies which have introduced workfare, have radically restructured the relationship between the (p.162) state, society and people with ill health or a disability. I have also examined some of the key debates around health related worklessness including whether it is an employment or a health issue, as well as discussions about how high levels of structural health related worklessness have been attributed to ‘cultures of worklessness’. I have also examined the medicalisation of sickness absence and the extent to which health related worklessness creates a ‘reserve army of labour’. Socio-economic inequalities in health related worklessness have also been examined as well as variation by welfare state. Here I have shown that whilst there are inequalities in the employment consequences of long-term ill health and disability across all advanced welfare states, they are most pronounced in the Liberal welfare states, and smallest in the Social Democratic ones. This shows that the political, economic and social context has important implications in terms of the employment consequences of ill health and that there are policy mechanisms available to enhance the employment of those with ill health as well as to reduce inequalities in health related worklessness. These are explored in more detail in the next chapter.

6.6 Further reading

Stone, D. A. (1986). The Disabled State, Basingstoke: Macmillan.

Organisation for Economic Cooperation and Development (2003). Transforming disability into ability: policies to promote work and income security for disabled people. Paris: Organisation for Economic Cooperation and Development.

Williams, G. H. (2010). ‘Understanding Incapacity’. In: G. Scambler and S. Scambler (eds.), New Directions in the Sociology of Chronic and Disabling Conditions: Assaults on the Lifeworld. London, Palgrave.


(1) Parts of this section are reproduced from Bambra and Smith (2010) reprinted by permission of the publisher Taylor & Francis Ltd.