Adrian Massey C Hurst & Co. Publishers Ltd, 2019, HB, 272pp, £20.00, 978-1787381223
Over 10 million sick-notes per annum may comprise as much as 10% of our workload. According to Adrian Massey, an experienced occupational health physician, most of this is an anachronistic charade. If 300 pages on sickness certification fill you with trepidation, persevere. This thought-provoking polemic is both erudite and wickedly entertaining.
Massey early on acknowledges a debt to the greatest of medicine’s iconoclasts. Ivan Illich coined the term ‘cultural iatrogenesis’ for the destruction of traditional ways of dealing with, and making sense of, death, suffering, and sickness.1 The medicalisation of everyday life proceeds apace. We the shamans continue to take confession and confer absolution. Meanwhile, the public retains a credulous belief in medical omnipotence and continues to entrust us with the power to adjudicate on their conditions.
Certification is predicated on the notion that sickness is the consequence of disease. Many of the conditions of modern life (for example, fibromyalgia, irritable bowel syndrome, chronic fatigue, and stress) are diagnoses only loosely rooted in medical science. Despite improvements in the population’s health, sickness rates have increased along with time off work and the burden of sick pay.
The statistics still startle. After being off work for 6 months, only 1 in 5 return to work. After 2 years, the employee is more likely to die or retire than return to work.2 The annual bill for sickness benefit is around £15 bn for 2.3 million recipients.3 Few claims are fraudulent but Massey estimates that between 50 and 75% of claimants could conceivably re-enter workplaces were the latter more accommodating.
His ire extends to the welfare state as a whole. A grotesque caricature of Beveridge’s original vision, he thinks it has corrupted the charitable ideals that originally underpinned it. Better living standards over time have been associated with increased entitlement, reduced sense of duty to work, and lowered resilience.
In other words, rising levels of sickness are a social phenomenon.
Along the way, Massey minces a veritable herd of sacred cows. He takes a big swipe at the use of dubious mental health statistics and is disdainful of venal politicians who have repeatedly sought to massage unemployment figures by reclassifying people as sick. He is especially withering on the effects of the law and a system ill-prepared for ‘the assorted roadkill of life’s poor driving’. He deems the Equality Act a costly failure.
Massey’s waspish wit is sometimes distracting. Evidence apparently suggests that ‘20% of managers are psychopaths who happen to have made it into the boardroom rather than prison’.4 (Of what proportion of doctors could something similar be said?) He sometimes overstates his case but this is no reactionary diatribe.
Massey is attempting to address the baleful consequences of doctors’ inability to define incapability and his solutions merit serious consideration. Beyond abolishing the certification process, he proposes scrapping existing Statutory Sick Pay and directing those funds to disability and unemployment benefits. This could save £3/4 bn. Extending the period of self-certification and an online Dr Sicknote are smaller advances. His most provocative idea uses National Insurance contributions to build personal pots of sick pay akin to a pension. Healthy employees would receive a small nest egg on retirement. He has much to say about how employers can better improve the resilience of their workforce.
Will anyone listen? The augurs are dispiriting. This is a book for policymakers and doctors but anyone involved in management will learn from it.
Adrian Massey’s ideas alone won’t save the NHS but politicians should take note.
- © British Journal of General Practice 2019
