‘Can I have one last present?’ my daughter asked earlier this week, having turned 15 and covered the kitchen floor with torn wrapping paper. ‘Can I have a sick note for PE?’
Doubtless she’d pored over that morning’s news before charging up and down the corridor at dawn to wake her parents. She must have noted that the government is planning to trial reforms of the sick note system that has been failing this country for decades.
She didn’t mention it when delightedly seeing if her squeezy pickled cucumber lamp would work (it did), or when she opened her new records (my wife having binned my several hundred, a timely few months before my daughter discovered vinyl). But she rarely asks for sick notes, or to miss school; she has the idea you shouldn’t. As habits go, this is a good one. Presume that you can generally struggle on and you generally do. There are times when we all fail and when adopting the sick role is absolutely the right choice, but it helps if doing so is very strongly not to our taste.
Across Europe, inactivity has been falling since the pandemic; in Britain it keeps climbing
William Beveridge said we must attack the giants of Want, Disease, Ignorance, and Squalor:
Abolition of Want in the sense in which that word is used here does not mean satisfying all desires. The extent to which the standard of living can be kept above the national minimum depends upon the degree of success achieved in dealing with the fifth giant: Idleness.
If Beveridge could see what had happened to incapacity, he would recognise his fifth giant at once. From about half a million back then it rose to a million odd in the 1980s. When it hit 1.5 million under Major in the nineties, Peter Lilley, Secretary of State at the Department of Social Security, declared he would ‘close down the something for nothing society’. In response, Spitting Image portrayed him as a Nazi camp commandant. The actual effect of his brutal clampdown was that the number of long-term sick continued to rise.
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Today we’re not far off three million whose sick notes harden into a life lived off the state. This is not good for us and it’s not good for them. We have a duty to help. Medical progress has coincided with a relentless rise in the long-term sick. Musculoskeletal conditions – a vague category, but accounting for a large share of those lost to illness – have gone up over the same decades in which treatments have improved. And the rise in mental illness is even more dramatic. The Office for National Statistics reports that ‘depression, bad nerves or anxiety’ affect more than half the long-term sick.
Across Europe, inactivity has been falling since the pandemic; in Britain it keeps climbing. Our problems cannot be explained by infection or emerging biochemical abnormalities. That doesn’t mean they’re not real – depression is all in the mind, and is no fiction – but it does mean they’re unlikely to yield to a pill. To be condemned to idleness by disability is miserable. The question is how best to help people and how best to help the state.
The government does not seem to be planning to cap sickness, like food prices. (Perhaps they should be more ambitious. Would infirmity, like the bond markets, fall into line for Andy Burnham?) Instead the news is of a trial that will test four different ways of helping those whose ill-health threatens their ability to work. Two of the strategies will involve patients bypassing their GPs – traditional gatekeepers of sick-notes – and seeing ‘social prescribers’ instead. These nebulous staff will have access to paramedical treatments, from counselling to gym classes like the one my daughter begged a birthday favour to escape.
Medicine’s skill in the design of clinical trials, more than any advance in drug design, has been responsible for post-war improvements in health. What doctors discovered – and what politicians refuse to realise – is that you cannot determine what works without good experimental method. Ideas need testing.
Our system of sick notes is obviously failing, and every effort to make it better has not changed the trend for it to keep getting worse. Proper trials of different strategies, capable of robustly determining which do best, are badly needed. The Department of Health and Social Care likes the word ‘trial’ but won’t take the trouble to understand what it means. Like the rest of government, it prefers experiments too badly designed to merit the name, or yield reliable answers.
‘Show me the incentive and I’ll show you the outcome,’ said the American businessman Charlie Munger. Everyone would agree our current system is failing. Changing the incentives is essential if we are to change the outcome. Real trials of different approaches would evaluate policies on their efficacy, not the cleverness of their theory or the virtue of their intentions.
My daughter got her sick note by virtue of having been poleaxed with illness until yesterday, not as a gift. Beveridge’s idle man had no job; today’s has a diagnostic label which may feel like a gift but can end as a curse. Will the new trial reverse the steady climb of Britons on long-term sick leave, or is the government just going to add another layer of ineffective bureaucracy and feel pleased it’s taken action? One would have to be a fool to be optimistic, a miser not to hope.
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