Sick Note—A History of the British Welfare State by Gareth Millward review

Sick Note—A History of the British Welfare State by Gareth Millward

This interesting book traces the history of the sick note from the birth of the welfare state in 1948 to today. And it looks at the relationship between the state, the employer, the doctor and the patient.

A GP writing in the Lancet in 1947 sums up how things were seen at the birth of the NHS. “Certification is the crux of the problem,” he writes. “The government is going to control the doctor, because if the doctor were not controlled, he might be ‘lax or dishonest’ or worse still, he might treat his patients with kindness and humanity.

“And who defines satisfactory certification? The Minister of Health and his officials. Perhaps when a production drive is in progress the Minister of Labour may arrange a further tightening up of certification.”

GPs were not specialists in occupational health and did not have access to sophisticated equipment to assist diagnosis. Their other concern was the volume of work that provision of a sick note would create—and that would take them away from treating patients.

After the Second World War, the state wanted to see an increase in productivity to pay off war debt. Increases in absenteeism were blamed on individuals’ reluctance to work and “abuse” of the new welfare state. Yet trade unions, which also monitored absenteeism, pointed out it was linked to the strain that employers put on workers’ health.

The book shows how the welfare state was designed for white, male “bread winners” who paid national insurance and received sick pay from the state through the sick note. The so-called “deserving poor”, who could not work, received national assistance and from 1968 Supplementary Benefit. Married women—even those paying full national insurance—did not receive the same sickness benefit.

There was state racism directed at migrants arriving from the Commonwealth who had a right to British citizenship. Even though black and Asian migrants claimed 55 percent less benefits than the general population, politicians and the press pushed the myth that people came to Britain to claim benefits. In 1972 the then Tory government commissioned the Fisher Report to investigate social security fraud. It showed there was no systematic abuse from claimants coming from outside of Britain.

In July 1982, after lobbying from the BMA doctors’ organisation, people could sign off work for the first week without a doctors’ note. However, for Margaret Thatcher’s neoliberal government, this was about privatisation of short-term sickness benefits. Now bosses, not the National Insurance Office, were responsible for administering sick pay for the first eight weeks. Employers would be compensated by a National Insurance rebate. This meant they’d be more focused on cracking down on absenteeism.

The TUC union federation raised concerns about confidentiality and exposure of personal and medical history. Disability rights campaigners highlighted how this would increase employment discrimination.

Now the Department of Health and Social Security turned its attention to the cost of chronic sickness, disability and unemployment. Deindustrialisation had seen a rise in unemployment. People, whose health had been badly damaged by their work, now claimed disability benefits.

Disability benefit costs, introduced in 1971, had increased from £196 million in 1972-73 to £7.7 billion in 1994-95. Peter Lilley, the Tory welfare secretary, fuelled the right wing press with talk of “closing down a something-for-nothing society” and ending “bad back benefit”. The offensive was joined by the media which talked of a “sick note culture. It attacked everyone from footballers like Darren Anderton to work-shy character Bert Quigley in the TV series London’s Burning. The press was critical of the emergence of newly identified conditions—workplace stress, ME, post-traumatic stress syndrome, Gulf war syndrome and AIDs.

Lilley pushed the need for reform. He proposed a new “At Work” test, replacing GP assessments with a scoring system that measured a person’s ability to stand, walk, see, speak. Many people, who clearly couldn’t work, were denied disability benefits.

However disabled people had been organising, inspired by resistance of women’s, anti-racist and LGBT+ movements. It led in 1995 to the passing of the Disability Discrimination Act.

After 1997, Tony Blair’s Labour government continued cracking down on benefit claimants. It brought in a policy called “Make work pay”, and commissioned a report by Carol Black called “Working for a healthier tomorrow”. The underlying premise was that being at work was good for health and well-being. It promoted the expansion of occupational health to reduce the time workers spent off sick and prevent long term sickness. 

Blair’s successor, Gordon Brown, brought in the “Fit note” in 2010 to replace the sick note. It was an electronic form for GPs to assess what a patient could do at work, designed to help bosses and workers negotiate a return to work. It ignored the reality of large numbers of people working in the new gig economy, where work was increasingly digital, service based and precarious. The “Make work pay” policy focused on pushing workers into jobs that didn’t suit their experience, qualifications or preferences.

In 2006 the TUC argued the idea that people are reluctant to work is a myth. In fact, in 2008 the Chartered Management Institute had shown unpaid overtime by workers was worth far more than the cost of sickness absence.

The Covid pandemic brutally exposed huge problems in Tory Britain. Millions were on zero hours contracts, freelancing or self-employed—not by choice but due to the way companies organised. Many were not entitled to Statutory Sick Pay—or, at £95.85 per week, could not afford to be off work.

Yet the pandemic meant isolating was central to public health. The government was forced to increase funds to £500 per week for those asking to isolate, bring in the furlough scheme and agree to remote working where possible.

The book closes with a recognition of this changing world with greater state intervention in the economy. It argues for “the need to provide safety nets and prophylactics against ill health and poverty”. However, it concludes that employers aren’t about to abandon their disciplinary procedures to get people into work. And “the least objectionable and most widely understood tool that can help these matters is still the humble sick note”.  

For all those interested in the welfare state this is a useful read. We face the new Liz Truss government and a cost of living crisis of unprecedented scale. It has never been clearer that we need to end zero hours contracts and fund the NHS and benefit system by taxing the rich. But, above all, we need to end the system based on profit not human need.

• Sick Note—A History of the British Welfare State by Gareth Millard (£25.00)