The Medical Aspects
SIXTH EDITION
Edited by
John Hobson
Julia Smedley
Great Clarendon Street, Oxford, OX2 6DP, United Kingdom
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Abbreviations ix
Contributors xv
1 A general framework for assessing fitness for work 1
John Hobson and Julia Smedley
2 Legal aspects of fitness for work 25
Gillian S. Howard
3 The Equality Act 2010 50
Mark Landon and Tony Williams
4 Ethics in occupational health 85
Steve Boorman and Diana Kloss
5 Health promotion in the workplace 103
Steve Boorman
6 Health screening in occupational health 121
David Koh and Tar-Ching Aw
7 The older worker 135
Steven Nimmo
8 Women’s health and other gender issues at work 162
Blandina Blackburn and Patrick Bose
9 Sickness absence 184
Richard Preece
10 Rehabilitation and return to work 207
Danny Wong
11 Fitness for work after surgery or critical illness 229
Tony Williams and Neil Pearce
12 Ill health retirement 262
Jon Poole and Glyn Evans
13 Medication and employment 275
Caroline Swales and Peter McDowall
14 Drugs and alcohol in the workplace 297
David Brown and David Rhinds
15 Transport 319
Tim Carter, Rae-Wen Chang, Andrew Colvin, and Robbert Hermanns
16
Seafaring, offshore energy, and diving 340
Tim Carter, Sally Bell, Mike Doig, Robbert Hermanns, and Phil Bryson
17 International travel 368
Dipti Patel
18 Health effects of vibration 381
Ian Lawson and Roger Cooke
19 Mental health and psychiatric disorders 398
Richard J.L. Heron and Neil Greenberg
20 Musculoskeletal conditions, part 1: rheumatological disorders 424
Syed Nasir and Karen Walker-Bone
21 Musculoskeletal conditions, part 2: spinal disorders 439
Birender Balain and John Hobson
22 Musculoskeletal conditions, part 3: disorders of upper and lower limbs 468
Sam Valanejad, Julia Blackburn, and Karen Walker-Bone
23 Neurological disorders 506
Jon Poole and Richard Hardie
24 Epilepsy 540
Ian Brown and Martin C. Prevett
25 Diabetes mellitus and other endocrine disorders 562
Ali Hashtroudi and Mayank Patel
26 Cardiovascular diseases 587
Joseph De Bono and Anli Yue Zhou
27 Respiratory disorders 616
Kaveh Asanati and Paul Cullinan
28 Dermatological disorders 647
Hanaa Sayed and John English
29 Cancer survivorship and work 660
Philip Wynn and Elizabeth Murphy
30 Vision and eye disorders 682
Stuart J. Mitchell and John Pitts
31 Hearing and vestibular disorders 710
Julian Eyears and Kristian Hutson
32 Hidden impairments 726
Marios Adamou and John Hobson
33 Gastrointestinal and liver disorders 746
Ira Madan and Simon Hellier
34 Blood-borne viruses 767
Paul Grime and Christopher Conlon
35 Haematological disorders 802
Julia Smedley and Richard S. Kaczmarski
36 Renal and urological disease 824
Christopher W. Ide and Edwina A. Brown
Index 843
Abbreviations
ACJ acromioclavicular joint
ACL anterior cruciate ligament
ACR albumin:creatinine ratio
ADHD attention deficit hyperactivity disorder
AED antiepileptic drug
AF atrial fibrillation
AIHA autoimmune haemolytic anaemia
ALT alanine transaminase
AME aeromedical examiner
AMED Approved Medical Examiner of Divers
APD automated peritoneal dialysis
ARDS acute respiratory distress syndrome
ART antiretroviral treatment
AS ankylosing spondylitis
ASD atrial septal defect; autism spectrum disorder
ATCO air traffic controller
BAC blood alcohol concentration
BCG bacillus Calmette–Guérin
BGL blood glucose level
BHIVA British HIV Association
BMA British Medical Association
BMI body mass index
BNF British National Formulary
BOFAS British Orthopaedic Foot and Ankle Society
BP blood pressure
BPPV benign paroxysmal positional vertigo
CAA Civil Aviation Authority
CABG coronary artery bypass grafting
CAD coronary artery disease
CAPD continuous ambulatory peritoneal dialysis
CBT cognitive behavioural therapy
CCS Canadian Cardiovascular Society
CES cauda equina syndrome
CHD coronary heart disease
CI confidence interval
CIPD Chartered Institute of Personnel and Development
CJEU Court of Justice of the European Union
CKD chronic kidney disease
CMD common mental disorder
CNS central nervous system
CO carbon monoxide
COPD chronic obstructive pulmonary disease
COSHH Control of Substances Hazardous to Health
CPAP continuous positive airway pressure
CRPS complex regional pain syndrome
CT computed tomography
CTS carpal tunnel syndrome
CVD cardiovascular disease
DCD developmental coordination disorder
DCI decompression illness
DDA Disability Discrimination Act 1995
DKA diabetic ketoacidosis
DMAC Diving Medical Advisory Committee
DMARD disease-modifying antirheumatic drug
DOAC direct oral anticoagulant
DSE display screen equipment
DSM-5 Diagnostic and Statistical Manual of Mental Disorders, fifth edition
DVLA Driver and Vehicle Licensing Agency
DVT deep vein thrombosis
DWR Diving at Work Regulations 1997
EAGA Expert Advisory Group on AIDS
EASA European Aviation Safety Agency
EAT Employment Appeal Tribunal
EAV exposure action value
ECG electrocardiogram
EDSS Expanded Disability Status Scale
EEG electroencephalography
eGFR estimated glomerular filtration rate
EPP exposure-prone procedure
EqA Equality Act 2010
ERT emergency response team
ESA Employment and Support Allowance
ESRD end-stage renal disease
ESWT extracorporeal shock-wave therapy
ET Employment Tribunal
EU European Union
FEV1 forced expiratory volume in 1 second
FMS fibromyalgia syndrome
FOM Faculty of Occupational Medicine
FVC forced vital capacity
GDM gestational diabetes mellitus
GFR glomerular filtration rate
GHJ glenohumeral joint
GMC General Medical Council
GSL general sale list
HASAWA Health and Safety at Work etc. Act 1974
HAVS hand–arm vibration syndrome
HbA1c glycosylated haemoglobin
HBV hepatitis B virus
HCV hepatitis C virus
HCW healthcare worker
HD haemodialysis
HHS hyperglycaemic hyperosmolar state
HIV human immunodeficiency virus
HLA human leucocyte antigen
HPV human papillomavirus
HR human resources
HSE Health and Safety Executive
HSL Health and Safety Laboratory
HTV hand-transmitted vibration
ICD implantable cardioverter defibrillator
ICD-10 International Classification of Diseases, tenth revision
ICOH International Commission on Occupational Health
ICU intensive care unit
Ig immunoglobulin
IHD ischaemic heart disease
IHR ill health retirement
IIDB Industrial Injuries Disablement Benefit
ILAE International League Against Epilepsy
ILO International Labour Organization
IMO International Maritime Organization
INR international normalized ratio
ISO International Organization for Standardization
IT information technology
ITP idiopathic thrombocytopenia
IVF in vitro fertilization
LASIK laser-assisted in situ keratomilieusis
LR likelihood ratio
LTD long-term disability
MCA Maritime and Coastguard Agency
MHRA Medicines Healthcare products Regulatory Agency
MI myocardial infarction
MPS Medical Protection Society
MRC Medical Research Council
MRI magnetic resonance imaging
MRO medical review officer
MRSA methicillin-resistant Staphylococcus aureus
MS multiple sclerosis
MSD musculoskeletal disorder
MTP metatarsophalangeal
MTPT methyl-4-phenyl-1,2,3,6-tetrahydropyridine
NGPSE National General Practice Study of Epilepsy
NHS National Health Service
NICE National Institute for Health and Care Excellence
NIHL noise-induced hearing loss
NMC Nursing and Midwifery Council
NPS new psychoactive substances
NPV negative predictive value
NSAID non-steroidal anti-inflammatory drug
NYHA New York Heart Association
OA osteoarthritis
OGUK Oil & Gas UK
OH occupational health
OPITO Offshore Petroleum Industry Training Organisation
OR odds ratio
ORR Office of Rail and Road
OSA obstructive sleep apnoea
OTC over-the-counter
PCI percutaneous coronary intervention
PCOS polycystic ovary syndrome
PCP Pneumocystis (carinii) jirovecii pneumonia; provision, criterion, or practice
PCR protein:creatinine ratio
PD Parkinson’s disease; peritoneal dialysis
PEF peak expiratory flow
PEP post-exposure prophylaxis
PFO patent foramen ovale
PHI permanent health insurance
PID prolapsed intervertebral disc
PN peripheral neuropathy
PO Pensions Ombudsman
POAG primary open-angle glaucoma
PoM prescription-only medicine
PPE personal protective equipment
PPV positive predictive value
PTA pure tone audiometry
PTSD post-traumatic stress disorder
RA rheumatoid arthritis
RCOG Royal College of Obstetricians and Gynaecologists
RCS Royal College of Surgeons of England
RCT randomized controlled trial
ROC receiver operating characteristic
RPS Royal Pharmaceutical Society
RRT renal replacement therapy
RSSB Rail Standards and Safety Board
RV residual volume
SAMHSA Substance Abuse and Mental Health Services Administration
SCD sickle cell disease
SCRA synthetic cannabinoid receptor agonist
SCT stem cell transplantation
SLD specific learning disorder
SLE systemic lupus erythematosus
SMI serious mental illness
SNHL sensorineural hearing loss
SNRI serotonin–noradrenaline reuptake inhibitor
SSRI selective serotonin re-uptake inhibitor
T1DM type 1 diabetes mellitus
T2DM type 2 diabetes mellitus
TB tuberculosis
TIA transient ischaemic attack
TKA total knee arthroplasty
TLC total lung capacity
TOC train operating company
UK United Kingdom
US United States
UV ultraviolet
VA visual acuity
VTE venous thromboembolism
VTEC verocytotoxin-producing Escherichia coli
WBV whole body vibration
WRLLD work-related lower limb disorder
WRULD work-related upper limb disorder
Contributors
Marios Adamou
Consultant Psychiatrist, South West Yorkshire Partnership NHS Foundation Trust, UK; Visiting Professor, School of Human and Health Sciences, University of Huddersfield, UK
Kaveh Asanati
Consultant Occupational Physician, Epsom and St Helier University Hospitals NHS Trust; Honorary Clinical Senior Lecturer, National Heart and Lung Institute, Imperial College London, UK
Tar-Ching Aw
Professor of Occupational Medicine and Chair, Department of Community Medicine, United Arab Emirates University, United Arab Emirates
Birender Balain
Consultant Spine Surgeon, RJ&AH Orthopaedic Hospital, Oswestry, UK
Sally Bell
Chief Medical Adviser, UK Maritime and Coastguard Agency, UK
Blandina Blackburn
Consultant Spine Surgeon, RJ&AH Orthopaedic Hospital, Oswestry, UK
Julia Blackburn
Specialist Trainee in Trauma & Orthopaedics, University Hospitals Bristol NHS Foundation Trust, UK
Joseph De Bono
Cardiologist, Queen Elizabeth Hospital Birmingham NHS Trust, UK
Steve Boorman
Director of Employee Health, Empactis, UK
Patrick Bose
Obstetric Consultant, The Royal Berkshire NHS Foundation Trust, Reading, UK
David Brown
Consultant Occupational Physician, Gloucester, UK
Edwina A. Brown
Consultant Nephrologist, Department of Medicine, Imperial College London, Hammersmith Hospital, London, UK
Ian Brown
Consultant Physician in Occupational Health Medicine and Clinical Research Fellow, Oxford Epilepsy Research Group, Nuffield Department of Clinical Neurology, Oxford University and Oxford University Hospitals, Oxford, UK
Phil Bryson
Medical Director of Diving Services, Iqarus/International SOS, UK
Tim Carter
Professor Emeritus, Norwegian Centre of Maritime and Diving Medicine, Bergen, Norway
Rae-Wen Chang
Chief Medical Officer, Occupational & Aviation Medicine, NATS Aeromedical Centre, UK
Andrew Colvin
Consultant Occupational Physician, OH Assist Limited, UK
Christopher Conlon
Reader in Infectious Diseases and Tropical Medicine, University of Oxford; Consultant in Infectious Diseases, Nuffield Department of Medicine, John Radcliffe Hospital, Oxford, UK
Roger Cooke
General Practitioner, Whitbourn, UK
Paul Cullinan
Professor in Occupational and Environmental Respiratory Disease, National Heart and Lung Institute, Imperial College, UK
Mike Doig
Consultant Occupational Physician, UK
John English
Consultant Dermatologist, Queen's Medical Centre, Nottingham, UK
Glyn Evans
Clinical Lead, Pensions, Medigold Health, UK
Julian Eyears
Consultant Specialist in Occupational Medicine, UK
Neil Greenberg
Professor of Defence Mental Health, Kings College London, UK
Paul Grime
Consultant Occupational Physician and Honorary Clinical Senior Lecturer, Occupational Health Service, Guy’s and St Thomas’ NHS Foundation Trust, The Education Centre, St Thomas’ Hospital, London
Richard Hardie
Consultant Neurologist, Frenchay Hospital, Bristol, UK
Ali Hashtroudi
Clinical Director, Guy’s and St Thomas’ NHS Foundation Trust, UK; Honorary Senior Lecturer, Department of Primary Care and Public Health Sciences, Medical School, King’s College London, UK
Simon Hellier
Consultant Gastroenterologist, Gloucester Royal Hospital, UK
Robbert Hermanns
Honorary Senior Clinical Lecturer, Healthy Working Lives Group, University of Glasgow, UK; Consultant Physician in Occupational Medicine, Health Management Ltd., UK
Richard J.L. Heron
Vice President Health, BP International, UK
John Hobson
Honorary Senior Lecturer, College of Medical and Dental Sciences, University of Birmingham, UK
Gillian S. Howard Employment lawyer, UK
Kristian Hutson
Specialist Registrar ENT Surgery, Sheffield Teaching Hospitals
Christopher W. Ide
Honorary Senior Clinical Lecturer, Healthy Working Lives Group, University of Glasgow; Consultant Physician in Occupational Medicine, Health Management Ltd., Altrincham, UK
Richard S. Kaczmarski
Consultant Haematologist, Hillingdon Hospital NHS Trust, The Hillingdon Hospital, Uxbridge, UK
Diana Kloss
Honorary President at Council for Work and Health, UK
David Koh
Distinguished Professor of Occupational Health and Medicine, PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Brunei Darussalam; Professor, SSH School of Public Health and YLL School of Medicine, National University of Singapore, Singapore
Mark Landon
Partner, Employment, Pensions and Immigration Team, Weightmans LLP, UK
Ian Lawson
Specialist Advisor HAVS Rolls-Royce PLC, Derby, UK
Ira Madan
Reader in Occupational Health, Kings College London, UK
Peter McDowall
GP Partner and Occupational Medicine
Trainee, Newcastle-upon-Tyne, UK
Stuart J. Mitchell
Consultant Occupational Physician, UK Civil Aviation Authority, UK
Elizabeth Murphy
Clinical director, NewcastleOHS, The Newcastle upon Tyne NHS Hospitals Foundation Trust, UK
Syed Nasir
Consultant, Occupational Health Group, Saudi Aramco, Saudi Arabia
Steven Nimmo
Occupational Physician, University Hospitals Plymouth NHS Trust, UK
Dipti Patel
Chief Medical Officer, Foreign and Commonwealth Office, UK and Director of the National Travel Health Network and Centre, UK
Mayank Patel
Consultant in Diabetes, University Hospital
Southampton NHS Foundation Trust, UK
Neil Pearce
Gastrointestinal Surgeon, University
Hospital Southampton NHS Foundation Trust, UK
John Pitts
CAA Medical Assessor and Consultant
Ophthalmologist, UK
Jon Poole
Consultant Occupational Physician, Sheffield Teaching Hospitals NHS Trust and the Health & Safety Executive, Buxton, UK
Richard Preece
Executive Lead for Quality of the Greater Manchester Health and Social Care Partnership, Manchester, UK
Martin C. Prevett
Consultant Neurologist, University Hospital Southampton NHS Foundation Trust, UK
David Rhinds
Consultant Psychiatrist in Substance Misuse/Clinical Stream Lead SMS, UK
Hanaa Sayed
Consultant, and Clinical Lead, Occupational Health and Wellbeing Services, Luton and Dunstable University Hospital NHS Foundation Trust, UK
Julia Smedley
Consultant Occupational Physician, Head of Occupational Health, University Hospital Southampton NHS Foundation Trust, UK
Caroline Swales
Consultant Occupational Physician for Roodlane, HCA Hospitals, UK
Sam Valanejad
Consultant Specialist in Occupational Medicine, UK
Karen Walker-Bone
Professor, University of Southampton, MRC Lifecourse Epidemiology Unit, Southampton General Hospital, UK
Tony Williams
Consultant Occupational Physician, and Medical Director, Working Fit Ltd., UK
Danny Wong
Senior Consultant Occupational Physician, Occupational Health Department, North Tyneside General Hospital, UK
Philip Wynn
Occupational Health Service, Durham County Council, UK
Anli Yue Zhou
Postgraduate Student, The University of Manchester, UK
A general framework for assessing fitness for work
John Hobson and Julia Smedley
Introduction
This book on fitness for work gathers together specialist advice on the medical aspects of employment and the majority of medical conditions likely to be encountered in the working population. It is primarily written for occupational health (OH) professionals and general practitioners (GPs) with an interest or qualification in OH. However, other professionals including hospital consultants, personnel managers, and health and safety professionals should also find it helpful. The aim is to inform the best OH advice to managers and others about the impact of a patient’s health on work and how they can be supported to gain or remain in work. Although decisions on return to work or on placement depend on many factors, it is hoped that this book, which combines best current clinical and OH practice, will provide a reference to principles that can be applied to individual case management.
It must be emphasized that, alongside relieving suffering and prolonging life, an important objective of medical treatment in working-aged adults is to return the patient to good function, including work. Indeed, the importance of work as an outcome measure for health interventions in people of working age has been recognized by both the government and the health professions, and was emphasized in the recent UK government report Improving Lives: The Future of Work, Health and Disability. 1 Patients deserve good advice about the benefits to health and well-being from returning to work so that they can make appropriate life decisions and minimize the health inequalities that are associated with worklessness. A main objective of this book is to reduce inappropriate barriers to work for those who have overcome injury and disease or who live with chronic conditions.
The first half of the book deals with the general principles applying to fitness to work and OH practice. This includes the legal aspects, ethical principles, health promotion, health surveillance, and general principles of rehabilitation. There are also chapters dealing with topics such as sickness absence, ill health retirement, medication, transport, vibration, and travel. These are specific areas that most OH professionals will be required to advise about during their daily practice.
The second half of the book is arranged in chapters according to specialty or topic. Most chapters have been written jointly by two specialists, one of whom is an occupational physician. For each specialty, the chapter outlines the conditions covered, notes relevant statistics, discusses clinical aspects, including treatment that affects work capacity, notes rehabilitation requirements or special needs at the workplace, discusses problems that may arise at work and necessary work restrictions, notes any current advisory or statutory medical standards, and makes recommendations on employment aspects of the conditions covered.
Health problems and employment
Workers with disabilities are commonly found to be highly motivated, often with excellent work and attendance records. When medical fitness for work is assessed, what matters is often not the medical condition itself, but the associated loss of function, and any resulting disability. It should be borne in mind that a disability seen in the consulting room may be irrelevant to the performance of a particular job. The patient’s condition should be interpreted in functional terms and in the context of the job requirements.
As traditionally used, impairment refers to a problem with a structure or organ of the body; disability is a functional limitation with regard to a particular activity; and handicap refers to a disadvantage in filling a role in life relative to a peer group (see Table 1.1).
Prevalence of disability and its impact on employment
Figures on the prevalence of disability in different populations vary according to the definitions and methods used and the groups sampled. There is no doubt that, however measured, disabling illness is common and an obstacle to gainful employment. Important information about the impact of long-term ill health on employment in the UK comes from the Labour Force Survey2 and the related Annual Population Survey3 (a locally boosted household survey). Data analyses from these and other sources informed a government green paper and public consultation on health, work, and disability in 2016.4 In these reports, long-term health conditions were defined as illness lasting for 12 months or more, and the subgroup of
Table 1.1 Definitions
Term Definition
impairment Any loss or abnormality of psychological, physiological, or anatomical structure or function
Disability Any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being
Handicap A disadvantage for a given individual that limits or prevents the fulfilment of a role that is normal
Source: data from world Health organization (1980). The International Classification of Impairments, Disabilities, and Handicaps geneva, Switzerland: world Health organization. Copyright © 1980 wHo
those who are disabled were defined as having reduced ability to carry out day-to-day activities (in line with the Equality Act 2010). The key conclusions were as follows:
◆ Among 11.9 million working-age people with a long-term health condition in 2016, 7.1 million were disabled.
◆ People in employment have better levels of well-being and lower risk of death than those who are out of work.
◆ Despite increasing rates of employment in the general population in recent years, fewer disabled people (48%) were employed compared with the non-disabled population (80% employed)—a gap of 32%.
◆ However, those with long-term health conditions that are not disabling have similar employment rates to people with no long-term health condition.
◆ There is a similar distribution of disabled people working across different industries and workplaces of various sizes, compared to non-disabled people.
◆ Disabled people are more likely to work part-time than non-disabled people.
In the UK, there are 3.4 million disabled people in work and 3.7 million out of work compared to 27 million non-disabled people in work and 6.7 million out of work. However, disabled people are twice as likely to leave work and nearly three times less likely to find work compared to non-disabled people.
With regard to common illnesses that affect those of working age:
◆ The overall cost of ill health among working-age people is around £100 billion annually.4
◆ Sickness absence is estimated to cost employers £9 billion annually.5
◆ About 14% of people with epilepsy are unemployed (compared to 9% of those with disability) but there is no evidence that those with epilepsy (or diabetes) are at increased risk of injury or absence.6
◆ A cohort study of 20,000 French electricity workers reported that diabetics were 1.6 times as likely as other workers to quit the labour force.7
◆ In England in 2014, 19% of people of working age had at least one common mental health condition. One in two people on out-of-work benefits had a mental health condition, compared to one in five of all working-age people and one in seven of those in full-time employment.8
◆ The Health and Safety Executive estimates that in 2014/2015, 1.3 million workingaged adults in Britain were suffering from an illness which they believed was caused or made worse by work, with 500,000 new cases each year. This caused 25.9 million lost working days and at a cost of £9.8 billion.9,10
The socioeconomic impact of working-age ill health is summarized in Box 1.1.11 Evidently, common as well as serious illness can prevent someone working, but many people who have a major illness do work with proper treatment and workplace support. Thus, the relation with unemployment is not as inevitable as these statistics suggest.
Box 1.1 Socioeconomic impact of working-age ill health
◆ 131 million days lost due to sickness absences in the UK in 2013.
◆ Minor illness, 27 million days; musculoskeletal, 31 million days; mental health, 15 million days.
◆ 4.4–6.9 days lost/employee/year.
◆ Sickness absence rates of 2.1–3.0%.
◆ Overall median cost of absence per employee estimated to be £554 or 2–16% of payroll.
◆ £14.5 billion paid out as Employment and Support Allowance in 2015/2016.
Source: data from Nicholson, PJ. Occupational health: the value proposition. London, UK: Society of Occupational Medicine. Copyright © Society of Occupational Medicine 2017.
Rather, the job prospects of people with common illnesses and disabilities can often be improved with thought, both about the work that is still possible and the reasonable changes that could be made to allow for their circumstances.
The relationship between work and health
Work forms a large part of most people’s lives and allows full participation in society, boosting confidence and self-esteem. The way people work has changed over the years. More women work outside the home, there is more shift work, and greater use of flexible hours. People may choose or need to work for longer. Jobs are no longer for life and during a working lifetime an individual is likely to do a variety of jobs and may work either full-time or part-time at different stages. Work need not necessarily be for financial gain; voluntary or charitable work brings many non-financial benefits of employment.
While work and health are intimately related, health is not a necessary condition for work, and work is not normally a risk factor for health. The beneficial effects of work generally outweigh the risks and many people work despite severe illness or disability. This reinforces economic, social, and moral arguments that work is an effective way to improve the well-being of individuals, their families, and their communities. However, the preconditions are that jobs are available, there is a realistic chance of obtaining work, preferably locally, allowance is made for age, gender, and (lack of) qualifications, and there are ‘good’ jobs from the perspective of promoting health and well-being.
The adverse health effects of unemployment and worklessness are now recognized. Unemployment causes poor health and health inequalities, even after adjustment for social class, poverty, age, and pre-existing morbidity. A person signed off work who is sick for 6 months has only a 50% chance of returning to work, falling to 25% at 1 year and 10% at 2 years. Most importantly, regaining work may reverse these adverse health effects and re-entry into work leads to an improvement in health. Worklessness and the problems it can bring are now recognized as an important public health issue in the UK.1
However, despite the health consequences of worklessness and comprehensive health and safety legislation, too many people are still injured or made ill as a result of their work. Unsafe working conditions may be a direct cause of illness and poor health. Improvements in health and safety risk management could prevent much avoidable sickness and disability. Thus, a balanced view of the relationship between work and health is desirable. Safety is important, but a healthy working life is much more than this, it enables workers opportunity, independence, and the ability to maintain and improve their own health and well-being and that of their families—a broader and more positive concept.
There are, thus, implications for the provision of advice about work and for sick certification. Sick certification is a powerful therapeutic intervention, with potentially serious consequences if applied inappropriately, including in particular the slide into long-term incapacity (Box 1.2).
Work—the advantages
◆ Important in obtaining adequate resources for material well-being and to be able to participate in society.
◆ Work and resulting socioeconomic status are the main drivers of social gradients in physical health, mental health, and mortality.
◆ Central to individual identity, social roles, and status.
◆ Important for psychosocial needs where employment is the expected normal.
◆ Good work is therapeutic and promotes recovery and rehabilitation.
◆ Associated with better health outcomes and reduces the risk of long-term incapacity.
◆ Minimizes the harmful physical, mental, and social effects of long-term sickness absence.
◆ Promotes full participation in society, independence, and human rights.
◆ Reduces poverty.
◆ Improves quality of life and well-being.
Worklessness—the disadvantages
◆ Higher mortality—cardiovascular lung disease and suicide.
◆ Poorer general health, long-term illness—hypertension, hypercholesterolaemia, repeated respiratory infections.
◆ Poorer mental health, psychological/psychiatric morbidity.
◆ Higher medical consultation, medication usage, and hospital admission rates.
◆ Overall reduction in life expectancy due to the above factors.
Box 1.2 Work versus worklessness
