The recently published economic inactivity rate (22.2%) for December 2023 to February 2024 for those aged 16-64 years of age is concerning: it has risen in the last quarter and is above estimates based on last year (December 2022-February 2023) (Office for National Statistics [ONS], 2024). In February 2024, there were approximately 2.83 million people with long-term sickness not working, in comparison to 1.97 million people not working for this reason in 2019. Before 2022, the previous peak in long-term sickness causing economic inactivity had been in October 2001, but the main reason at that time for not working was because of people looking after family members. Since December 2021, long-term sickness has been the main reason for economic inactivity and in December 2023 people being long-term sick accounted for 30.2% of those who were economically inactive (Clark, 2024). Although the reasons why long-term sickness has increased are unclear, it has been noted that onwards from 2022, mental health issues including anxiety and depression, are increasingly cited among the long-term health conditions, alongside long COVID (Clark, 2024). Importantly, it seems that long-term sickness is increasing more in younger people (16-34 years) compared to those aged 35-49 years, although the majority of long-term sickness continues to be seen in those aged 50 years or more.
The Chartered Institute of Personnel and Development (CIPD) (2023) reported a significant increase in sickness absence at 7.8 days on average per employee per year, which is 2 days more than in 2019 (5.8 days), and at its highest level in a decade. Interestingly, different industries have different rates of sickness with sickness rates rising faster in some industries compared to others (Access PeopleHR, 2024). Access PeopleHR collected absence data from over 1775 small and medium-sized businesses and noted a rise of 55% in sickness absence rates since 2019 (81 days in 2019 compared to 128 days in 2023). The industries with the fewest sickness absences were recruitment, and administrative and support service activities (12 days on average per company), with human health and social work activities ranked ninth with an average of 103 days per company. The worst industries ranked 17th and 18th, respectively, were manufacturing (199 days on average per company) and agriculture, forestry and fishing (255 days on average per company). Recruitment, and administrative and support service activities companies have seen a reduction in sickness absence between 2019 and 2023, while other industries have seen increases.
‘COVID-19 pandemic… likely created a change in attitudes away from ‘the show must go on’ and fewer feelings of guilt.’
For example, human health and social work activities companies have seen an increase of 33.03% (77 days in 2019 v 103 days in 2023). The largest increase (158.96%), albeit modest in terms of days lost, has occurred in the arts, entertainment and recreation companies (16 days in 2019 v 40 days in 2023). Their work is face-to-face in public spaces (theatres, leisure centres, museums, theme parks etc) which not only puts them in contact with potential infections, but there may also be more concern about sickness symptoms since the COVID-19 pandemic, which likely created a change in attitudes away from ‘the show must go on’ and fewer feelings of guilt when time off work is needed. This change in attitudes is probably not limited to those working in the arts, entertainment and recreation sector.
NHS England publishes monthly staff sickness data, albeit 3 months in arrears, so that December 2023 data were released in April 2024 (NHS England, 2024a). The overall sickness absence was 5.5%, slightly increased from November 2023 (5.3%) and has decreased from 6.3% reported in December 2022. There were regional and organisational differences; sickness absence in the North West region was 6.4% compared to London's 4.9%, and Ambulance Trusts reported 7.8% sickness absence compared to Commissioning Support Units at 3.3%. There were staff group differences, with staff providing support to ambulance staff reporting the highest rate of sickness absence at 9.1% compared to hospital and community services doctors at 2%. A quarter (25.6%) of sickness absence (equivalent to over 620 820 full-time-equivalent days lost) were attributed to mental health issues (anxiety, stress, depression or other psychiatric illnesses), which was echoed in the recent ONS data for the whole of the UK.
Health inequality
The global health status data shows more promising trends than the ONS data for the UK. The systematic analysis of Global Burden of Disease Study 2021 draws on 10,083 data sources to estimate years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries (Global Burden of Disease 2021 Diseases and Injuries Collaborators, 2024). It includes data for 2010–2021 to estimate trends in disease burden over the past decade and includes the first 2 years of the COVID-19 pandemic. Global DALYs increased from 2·63 billion (95% UI 2·44–2·85) in 2010 to 2·88 billion (2·64–3·15) in 2021 for all causes combined due to population growth and an ageing population as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7–17·3) 2010–2019. However, COVID-19 reversed these health improvements as evidenced by increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8–6·3) in 2020 and 7·2% (4·7–10·0) in 2021, and HALE decreasing by 2·2% (1·6–2·9) 2019–2021. Future analyses will confirm the long-term impact of COVID-19 on global health status trends.
Using pre-2024 ONS data, Watt et al (2023) projected that there will be 9.1 million people living with long-term illnesses by 2040 compared to 2.5 million in 2019. Much of the increase reflects an ageing population whose survival into advanced age is to be celebrated, but it also reflects the growing prevalence of anxiety, depression, chronic pain and diabetes.
This growing burden of ill health will increase demand upon primary care and other community-based services, but importantly, the projected increase of people with long-term illness is nine times greater than the expected growth in the working age population. This will impact the availability of funding, as well as the size of the caring workforce. Further, the prevalence of long-term illness will not be borne equally across the whole population. Inequalities in health will persist so that those living in the 10% most deprived areas are likely to have long-term illness diagnosed 10 years sooner than those living in the 10% least deprived areas (Raymond et al, 2024).
The importance of nurturing population health has long been acknowledged through public and occupational health initiatives, for example, ‘Make every contact count’ (Public Health England, 2016), ‘Every mind matters’ (NHS England, 2024a), ‘Health is everyone's business’ [Department for Work and Pensions and Department of Health and Social Care (DWP and DHSC, 2019)] and the Government's response to the consultation (DWP and DHSC, 2021). The CIPD (2023) has argued that sickness absence should not be viewed in isolation and be the only measure of an organisation's efforts to support their workforce's health and wellbeing. Importantly, there was no pandemic in 2019 when sickness absence was already increasing. Since then, there has been the COVID-19 pandemic and cost of living challenges, which have heralded enormous changes in many organisations which of themselves may impact workforce health and attendance. The CIPD reported a paradox that, while an increasing number of employers have implemented health and welbeing initiatives, more employees are reporting stress-related and other mental health issues. The CIPD's organisation survey 2023 found that most organisations had a health and wellbeing strategy or plan with more than half (54%) of employee activities focused on promoting mental health, including stress management (CIPD, 2023). Other health benefits included counselling services, flu vaccination, lifestyle advice, wellbeing days and in-house or discounted physical fitness opportunities. As in the NHS, investment in employee wellbeing was viewed as also promoting employee engagement as part of a workforce retention strategy. Interestingly, the variations in wellbeing support across the lifecourse was noted, the current emphasis being on parents of children to the neglect of those with older people caring responsibilities, long-term conditions or men's health issues. The recent publicity surrounding the needs of menopausal women is likely to have increased organisational support related to menstrual and menopausal health.
Not everyone works where there is accessible occupational and wellbeing support. As part of its £2.5 billion ‘Back to work’ plan to help people with long-term health conditions or disabilities and long-term unemployment to look for and stay in work, the Goverment has recently launched a new work and health support service in the form of WellWork pilots in 15 areas, including Greater Manchester and the Black Country where there are high numbers of people who cannot work due to ill health (DWP and DHSC, 2024). The WorkWell pilots are designed to facilitate discussions with employers about health needs, provide advice on workplace adjustments, including flexible working and adaptive technology, together with access to local services including physiotherapy, employment advice and counselling. It will be interesting to see to what extent this support helps individuals to achieve their work ambitions.
NHS annual staff survey 2024
The NHS undertakes an annual staff survey, with the 2023 survey results being published in March 2024 (NHS England, 2024b). The sample non-response rate is noteworthy and may introduce bias in terms of full NHS workforce representation (1.3 million invited; n=707,460 responded, of whom 19 184 respondents were registered nurses and registered midwives; an overall response rate of 48%). Nonetheless, it is a large sample of the workforce and participation is voluntary. Mallorie (2024) has observed that the results were more positive than in the 2022 survey, despite industrial action and rising demand, although two in five reported feeling unwell as a result of work-related stress during the last 12 months; midwives, paramedics and those aged 21–30 years were more likely to report work-related stress.
Some of the positive results included: 87.64% reported that they felt their role made a difference to patients, 75.14% reported that care of patients was their organisation's top priority, and 61.12% said they would recommend their organisation as a place to work. Most (circa 70% across all the questions) reported compassionate leadership. While the respondents were positive about their levels of autonomy and control, involvement in deciding on changes and making things happen attracted lower scores. Workload and adequate resources attracted some lower scores, which was echoed in the morale scores. Staff motivation, involvement in workplace decisions and feelings about their place of work were better than in 2022 (NHS England, 2024b). Over half of respondents (54.85%) reported that they had gone into work in the last 3 months despite not feeling well enough to perform their duties, but it is unclear whether this was because of physical health problems, work-related stress or other mental health issues. Similar trends have been noted across all employee sectors (CIPD, 2023; Access PeopleHR, 2024; ONS, 2024).
‘Positive mental health is defined as: ‘a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’
(WHO, 2001)’
Clark et al (2024) have noted the burgeoning demand for mental health services, with existing services unable to meet the current demand in a timely fashion. They also drew attention to varying perceptions of what mental health means. In part, this is because positive mental health has been categorised as wellbeing, while the care of those with mental illness/disorder remains under the medical supervision of psychiatry. Positive mental health is defined as: ‘a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’ (WHO, 2001). Thus, negative emotions and experiences are a part of life, and their impact should not undermine the ability of an individual to function in day-to-day life. Over a decade ago it was anticipated that good wellbeing services would the lower number of referrals to NHS mental health services at all levels (HM Government, 2011).
Today, wellbeing provision largely comprises services that involve non-healthcare professionals (including the voluntary sector). Unfortunately, training for wellbeing and health coaches remains unregulated, so there can be no certainty about the level of mental health training or service quality (Clark et al, 2024). Further, short mental health ‘first aid’ courses are only designed to equip coaches and other non-healthcare professionals with an awareness of mental health issues rather than give them the triage assessment or risk assessment/management skills of qualified healthcare professionals. In contrast, counsellors and psychotherapists are regulated by the British Association for Counselling and Psychotherapy (BACP) and are able to display their BACP registered status, most having graduated from a BACP-approved course. However, some ambiguity remains with regards to full membership and accredited status of the BACP.
The important bridge between wellbeing and tertiary mental health services is provided by GPs, nurses working in community settings and social workers, with more serious and enduring mental illness/disorders being treated and managed within psychiatric services, particularly during acute episodes. Undoubtedly, some people experience mental illness/disorders with recognisable symptoms or behaviours, and associated distress that interferes with normal life. However, it is difficult to assess whether the current levels of reported mental health issues, including anxiety and depression, are partly a reflection of diagnostic changes or a real increase in serious mental illness/disorders.
Whatever the reason, community nurses need to maintain their vigilance for those with mental health needs so that all appropriate clients and their carers or family, and colleagues are signposted to relevant support and services.