Challenging health inequalities--implications for the workplace

People's relationship with work, whether in work or out of work, their employment arrangements and the nature and conditions of that work, influences health to a remarkable extent. Work can promote good physical and mental health, work can have adverse effects on health, poor health can reduce the chances of gaining or maintaining a job and being out of work can damage health. Unravelling the mechanisms linking work and health has been the focus of the Whitehall Studies of British civil servants since the early observation of the social gradient in health: that people in the social hierarchy at work have worse health than those above them, and better health than those below them [1]. While population health in the UK, as measured by life expectancy, has improved significantly over recent years for all social classes, health inequalities, such as those identified by the Whitehall Studies, remain a persistent and unacceptable feature of our society. In England and Wales, the mortality rate for men aged 15–64 in the most deprived neighbourhoods is 2.5 times that in the least deprived neighbourhoods, and there is a gradient in between [2]. In addition, there is 17 years gap in disability-free life expectancy between people living in areas at the bottom 5% of the income distribution and people living in the best off areas [3]. Yet, health inequalities are not a natural and immutable feature of society. Nor are health inequalities simply a matter of inequalities in access to health care, although the health care system has an important role in mitigating health inequalities. Systematic health inequalities arise from inequalities in society. Observations that the pattern of health inequalities varies between countries and within countries across time indicate that health inequalities are responsive to political, economic, social and cultural change. Since this is so, there is an ethical imperative to reduce unnecessary suffering and premature death by taking action to eliminate or at least reduce systematic health inequalities. From this ethical perspective, the World Health Organization Commission on Social Determinants of Health (chaired by M.M.) examined evidence on the social determinants of heath and health inequities and advised on what can be done to reduce health inequities [4]. Three fundamental needs of individuals underpin action on health inequalities, as follows: the material requisites for a decent life; control over factors that influence their lives; and participation in society. Work, in particular, fair employment conditions and decent work [5], can help individuals fulfil these needs. The Strategic Review of Health Inequalities post 2010 [3] (‘Marmot Review’ chaired by M.M.) examined the implications of the WHO Commission's recommendations for England. Creating fair employment conditions and decent work for all emerged as one of the Marmot Review's six areas of recommendations in its advice to government, of any political flavour, for tackling health inequalities in the coming years. Globalization, technological innovation and the imperative of economic growth have characterized development over the past 40 years and have brought about profound changes both in employment conditions and the conditions of work. These changes impact on social groups differentially according to types of occupation, level of income and education, by gender, age and ethnicity/race, and where they live. Economic growth and technological innovation are widely considered essential for social progress, yet the hegemony of economic growth is currently being questioned by influential groups. The Commission on Social Determinants of Health promoted a paradigm of human development built on equity, implying fair distribution of the benefits of economic growth and technological innovation, and proposed that the distribution of health and well-being across society would be a robust indicator of how well a society is doing [4]. The Commission on the Measurement of Economic Development and Social Progress set up by President Sarkozy argued that ‘the time is ripe … to shift emphasis from measuring economic production to measuring people's well-being’ [6]. In the UK, the Sustainable Development Commission goes further, publishing a report entitled ‘Prosperity without growth?’ that proposes 12 steps to a sustainable economy, including sharing the available work and improving work–life balance, and measuring people's capabilities and flourishing [7]. In this context of global change and debate, there emerges a strong evidence base supporting the position that health inequalities flow from social and economic inequalities and the unequal distribution of power, prestige and resources [4]. Work is a major route whereby individuals gain prestige and resources that are beneficial to health and well-being. Being out of work not only limits income and access to material resources for health, but has profound psychosocial effects that can adversely affect health. While fair employment and decent work can bring economic, social and psychosocial benefits to individuals, a body of evidence shows that adverse employment and working conditions damage health and contribute to the social gradient in health [5,8]. Precarious employment conditions and job insecurity are associated with poor health outcomes, including adverse effects on mental and physical health [9]. Traditionally, occupational health has been concerned with ensuring that workers are safe from physical, chemical and biological hazards. Strong evidence now links stress at work, the imbalance between the demands of work and the degree of control over work or the imbalance between effort and reward, with adverse health outcomes including poor self-reported physical and mental health and coronary heart disease [8]. The level of social support from managers and co-workers influences mental health outcomes and affects sickness absence. Perception of organizational justice at work, including consistent and sufficient information from a line manager, a line manager who listens to problems about work, unfair criticism and praise, affects self-rated health. Such psychosocial working conditions are now receiving greater policy attention, for example through the Health and Safety Executive management standards approach to work-related stress, and the National Institute of Clinical Excellence guidance, mandatory for the National Health Service, on promoting mental well-being in the work place through supportive management practices. Building on the management standards approach, the Marmot Review recommends, inter alia, that the government should encourage by all appropriate means the implementation of guidance on stress management and the effective promotion of well-being and physical and mental health at work [3]. Much recent government interest has focussed on ways to break the link between ill health and being out of work and being out of work and ill health. Active labour market policies aimed at supporting people to enter work involve interventions including job search assistance and training programmes, as well as wage subsidies and job creation [10]. Evidence examined by the Marmot Review shows that participation in training programmes has the potential to benefit individuals in two ways: by enhancing skills and knowledge that help people gain entry into the job market and by having a positive effect on individual well-being and psychological health through psychosocial pathways such as social support and sense of control [10]. Where programmes enhance the social environment and boost self-efficacy and self-esteem of individuals, they play a role in promoting psychological well-being and preventing depression, which, in addition, increases employability. Dame Carol Black's review, ‘Working for a Healthier Tomorrow’, recommended expansion of occupational health services, and replacement of the traditional ‘sick note’ to sign people off work with a ‘fit note’ that focuses on what people are able to do and aims to keep them in work where appropriate [11]. At least 40% of people receiving incapacity benefits suffer mental health conditions. On this theme, the cross-government programme of action on mental health (New Horizons Strategy) [12] published in December 2009 announced initiatives aimed at combating the stigma of mental health and improving employment support for people with a mental health condition. The starting position of the Marmot Review is that the systematic differences in health between groups are largely determined by factors outside the health sector. Yet of course, it is the practitioners within the health sector, including occupational health practitioners and general practitioners at the primary level of care, who deal daily with those health outcomes that reflect the way society is organized. Indeed, health practitioners have a central role to play in advocacy, design and delivery of services that promote health and well-being. This applies both within the health service at the local level and across sectors, in working with employers and access to work programmes. The relationship between work and health must be understood and responded to by health practitioners; occupational health services must become more widely available, and they should be fully integrated into the National Health Service. Underpinning action to promote health and well-being is the idea of creating a social environment that enables individuals from all groups in society to have control over their lives and participate in society. Included in this approach is the role of individuals and community groups in helping to shape the services they use. The principles of a social environment that enables people to have control over their lives and participate in society apply equally to people who are not in employment and those who are no longer of working age. These principles embody universal values of fairness, respect and non-discrimination—a vital infusion for tackling health inequalities across society.