Reducing unemployment and its effects on health

Inequality
By the International Labour Office (ILO) definition, two million people were unemployed in the UK in 1997, about 7 per cent of the economically active population of working age. Around half of all unemployed men and just under a third of unemployed women had been unemployed for one year or more40. The risk of being unemployed is much higher for young adults, people from minority ethnic groups, disabled people and for people in less skilled occupations and with fewer qualifications40,45. For example, unemployment rates are four times higher among unskilled workers than among professional groups44, and three times higher for disabled than non-disabled people136. In addition to those recorded officially as unemployed, there are nearly 8 million people of working age in the UK who are classed as economically inactive because of long term sickness, for instance, or because they are looking after a family or have become discouraged in their search for work. A third of these report that they would like a job40. Many of the jobless households contain children, who share the consequences and living standards of their parents not being in employment. For example, of a total of 13.3 million dependent children in the UK in 1994-95, 4.1 million lived in households with no full-time worker, three quarters of whom were living in poverty (in a household below half of average income, after housing costs)72.

Evidence
For a small minority, unemployment appears to lead to an improvement in health. But for the majority it tends to have a significant adverse effect on both physical and mental health. Unemployment is an important determinant of inequalities in the health of adults of working age in Britain, with people lower down the social scale being hardest hit137-139. Unemployed people are found to have lower levels of psychological well-being, ranging from symptoms of depression and anxiety to self-harm and suicide140,141. In relation to physical health, unemployment carries a higher risk of morbidity and premature mortality. In the latest analysis from the Longitudinal Study covering England and Wales, for example, mortality from all major causes was consistently higher than average among unemployed men. Among younger men, mortality from injuries and poisoning, including suicide, was particularly high. Unemployed women had high mortality from coronary heart disease and injuries and poisonings, including suicide142. The wives of unemployed men have been found to have an excess risk of death143. Even after taking account of the more disadvantaged circumstances of unemployed people, an excess risk of death of more than 20 per cent remains142.

Explanations for how unemployment leads to poorer health centre on four main mechanisms: through increased poverty and hardship; through social exclusion (isolation, stigma); through changing health related behaviour; and through disrupting future work careers (people who experience a spell of unemployment are at greater risk of becoming unemployed again within the next two years)144. In relation to hardship, the financial consequences of unemployment are often instant and dramatic. Cohort studies of people entering unemployment show that, for many, their income was cut by half as they switched from wages to social security benefits145,146. The largest British cohort study in the 1980s showed that two thirds of unemployed people had a week's notice or even less, and only 1 in 10 received any form of redundancy payment. Two thirds were under 35, and most came from manual or lower service occupations, at the lower end of the pay scale and with low or no educational or technical qualifications144. Families with an unemployed head are at the highest risk of poverty147. Studies of the adequacy of state benefits identify unemployed households with dependent children as being particularly badly off148-151.

Some of the excess morbidity and mortality associated with unemployment may be a result of people in poorer health being more likely to become unemployed, rather than vice versa. The evidence suggests that selection of unhealthy people into unemployment does indeed occur, but it is not the dominant factor explaining the observed relationship between unemployment and excess risk of ill-health. It does, however, illustrate the double disadvantage that people with chronic sickness or disability may face: their ill-health puts them at greater risk of unemployment, and the experience of unemployment in turn may damage their health still further.

Unemployment is associated with lower levels of educational attainment152 and other skills. The lack of such skills may prove a barrier to obtaining employment153 reinforcing earlier or other disadvantage. For example, Labour Force Survey Data indicate that 41 per cent of disabled people of working age have no educational qualifications, compared with 18 per cent of non-disabled people154. Unemployment is particularly high amongst young people. The rates of unemployment among people up to the age of 25 years are about twice as high as for all adult workers155. Schemes to raise levels of skills amongst people without a job, particularly young people, have been important components of Government policies over the last 20 years or so. Evaluations of policies that have aimed to increase levels of skills among young people have reached differing conclusions. Some have concluded that such training increases likelihood of "a good job", whilst others have found that such success is very limited156-160. In particular, such schemes may fail the most disadvantaged by not addressing other problems, such as homelessness or lack of social support, which may present greater barriers to employment than lack of skills161. "Foyer" schemes are an example of a broader approach to disadvantage amongst unemployed young people. They consider the need for housing and social support as well as training and employment, but have yet to be thoroughly evaluated162,163.

Many jobless households contain children, the majority living in poverty. Parents, especially lone parents, who wish to take up work may face several barriers. These include a lack of affordable child care, limited flexibility in parental leave and leave to care for sick children, and excessive and unsociable working hours. By comparison with many other member states of the European Union, the United Kingdom's policies in this area are limited. For instance, the UK has no provision for parental leave or leave to care for sick children, whereas half the (mainly European) 20 countries in a recent study had arrangements for leave to care for sick children164. The Inquiry welcomes the publication of the Government's white paper "Fairness at Work"165, issued in May 1998, with its commitment to "family-friendly policies". We consider that this is an important, if modest, step in the right direction, and commend the further development of such policies. Consequently, with the exception of day care for children, we have not made a specific recommendation in this area.

But the removal of barriers to work for parents with dependent children, and higher levels of skills and additional training will achieve little unless there are jobs available. Indeed, lack of availability of employment may increase the sense of exclusion of people who are unable to gain employment despite adequate levels of skills161. It is outside the scope of the Inquiry to recommend specific policies on employment creation. However, we consider that increasing employment opportunities is crucial to reducing inequalities in health.

Benefit
Improved financial support during unemployment should improve material living conditions and resources needed for health, including access to food, heating, and shelter. It may also improve the ability of unemployed people to take part in the life of their communities - reducing social exclusion.

Policies aimed at the creation of employment opportunities, improved levels of education and training for young unemployed people, and removal of barriers to work for parents with dependent children should increase the chances of health enhancing employment in addition to other beneficial effects on health and its determinants, for example, income.

8. We RECOMMEND policies which improve the opportunities for work and which ameliorate the health consequences of unemployment. Specifically:

8.1 we recommend further steps to increase employment opportunities.

8.2 We recommend further investment in high quality training for young and long term unemployed people.

We recommend policies which will further reduce income inequalities, and improve the living standards of households in receipt of social security benefits (recommendation 3).

We recommend an integrated policy for the provision of affordable, high quality day care and pre-school education with extra resources for disadvantaged communities (recommendation 21.1).

Improving the quality of jobs

Inequality
For those in paid employment, there have been major changes in the nature of work over the past two decades. Along with greater labour market flexibility and deregulation of employment contracts has come greater job insecurity. Indeed, it could be considered that the concept of a secure "job for life" is now obsolete. While all sections of the workforce have been affected by these trends, less skilled manual workers at the lower end of the labour market have been affected the most, in terms of greater exposure to low paid, temporary and insecure employment166-169.

There is also a growing recognition of the impact of stressful working conditions on health. Popular opinion tends to equate stress at work with pressure of work. Surveys which ask about self-perceived pressure of work have found that people in higher socioeconomic groups report such pressure more frequently170. However, evidence of health related harm is associated more with specific psychosocial factors such as imbalance between psychological demands and control, and lack of control at work171. Exposure to high demand and low control is more common among lower socioeconomic groups172.

Evidence
A number of studies from the UK and elsewhere in Europe and from the USA show that an imbalance between psychological demands and control, and lack of control at work are associated with increased risk of coronary heart disease, musculoskeletal disorders, mental illness, and sickness absence171-176. As these psychosocial factors are related to the organisation of work, there are opportunities for change.

A recent review of international case studies on improving psychosocial health in the workplace found that it was possible to make improvements by tailoring changes to specific workplaces177. Examples included increasing the variety and understanding of the different tasks in a production process, workforce participation in identification of problems and their solutions, and altering shift patterns to make them less tiring and disruptive to workers' personal lives. Furthermore, some changes in workplace organisation resulted in improved productivity. Although effective changes were likely to be specific to particular workplaces, successful interventions had some common features177. They were: appropriate commitment and effort from management; support by management and the workforce; participation of the workforce in planning and implementation; and the creation of trust. Conversely, aspects which inhibited the success of policies included: schemes which directed attention away from difficult working conditions and attempted to treat the symptoms only; technical solutions alone, imposed from the top; and cases where management retained control over the dialogue.

Successful interventions follow principles of good management practice178. Current Health and Safety Executive (HSE) Guidance endorses this179. The enhancement of management skills in the current and future workforce is likely to bring about both a culture and practice which is amenable to health-promoting work organisation and practices. Good management practice may be engendered during school years, particularly in the acquisition of "life skills"121 as a component of Personal, Health and Social Education, and within the context of health promoting schools. Enhancing the management skills of the current workforce, particularly in relation to the promotion of psychosocial health, may be aided by further guidance and development work by the HSE, such as extending the current "Good health is good business" campaign to include psychosocial health180. It has been suggested that good practice might also be encouraged by extending psychosocial health and safety issues to award schemes, such as "Investors in People". Other options include extending existing HSE regulations to encompass psychosocial health.

Evidence from Scandinavia suggests that good practice may also be promoted by explicit commitment and leadership from the national level177,181. In this respect, we welcome the Government's white paper "Fairness at Work", which has the stated aim of "putting a very minimum infrastructure of decency and fairness around people in the workplace"165. In pointing out that Britain now has the most lightly regulated labour market of any leading economy in the world, it explicitly acknowledges the unfairness of this situation - denying British citizens basic employment rights that are a matter of course elsewhere. Some of the measures proposed in the white paper have the potential to influence health related psychosocial conditions at work, in particular in relation to job security. Assessing the impact on health of existing and proposed employment policies, such as these and the Welfare to Work scheme, will be crucially important to inform future policy-making.

Benefit
Improved work practices, together with complementary employment policies, should decrease psychosocial ill health and its consequences, and may have other gains, including economic gains for the individual and society.

9. We RECOMMEND policies to improve the quality of jobs, and reduce psychosocial work hazards. Specifically;

9.1 we recommend employers, unions and relevant agencies take further measures to improve health through good management practices which lead to an increased level of control, variety and appropriate use of skills in the workforce.

9.2 We recommend assessing the impact of employment policies on health and inequalities in health (see also recommendation 1).

4. Housing and Environment

Shelter is a pre-requisite for health. However, people who are disadvantaged suffer both from a lack of housing and from poor quality housing. Furthermore, the fear of crime compounds the social exclusion of people living in disadvantaged areas. This section sets out inequalities in housing and the environment and health and summarises the evidence which we have concluded indicates areas for future policy development. These areas are improving the availability of housing, improving its quality and increasing the safety of the environment in which people live. The section also summarises the benefits which might result from such policies.

Improving the availability of housing

Inequality
As a result of housing policy in the 1980s and early 1990s, social rented housing - local authority and housing association homes - has increasingly become a housing sector for low income groups. People moving into social housing have tended to be families with children on the lowest incomes while those moving out have been older, with higher incomes and fewer children182. The result is an over-concentration and separation of households with high levels of need in areas with poor amenities.

The last 20 years have also seen a rapid increase in homelessness, with the numbers of officially homeless families peaking in the early 1990s183. In 1997, 165,690 households were estimated to be homeless. Of these 103,340 were officially homeless, that is they met the definition of homelessness laid down in the 1977 Housing (Homeless Persons) Act. The remainder were unofficially homeless, including rough sleepers - those without any accommodation at all - and hostel users51. Because it is difficult to be accepted as officially homeless without the presence (or imminent arrival) of children, the officially homeless population contains a large number of mothers and dependent children. Fifty seven per cent of officially homeless households had dependent children, and a further 10 per cent had a pregnant household member. Seven per cent had a household member vulnerable through mental illness51. Over a third of the officially homeless are drawn from minority ethnic groups184. By contrast, minority ethnic groups are not over-represented among the unofficial homeless population, which is older and predominantly male (70 per cent of hostel users and 85 per cent of rough sleepers are men)184. Young people constitute a significant and high risk sub-group among the unofficially homeless population185.

Rough sleepers are also drawn disproportionately from those who have been in an institution such as prison or mental hospital or have been in local authority care.

Evidence
Very high mortality rates have been recorded for homeless people, particularly for rough sleepers and hostel users186. Surveys also point to high levels of health need among the homeless population. Forty five per cent of the bed and breakfast population have been found to experience psychological distress, compared to 20 per cent of the general population184. Rates of self-reported depression and anxiety are three times higher among those in bed and breakfast accommodation and ten times higher in rough sleepers. There is also an elevated prevalence of major mental disorders, most notably schizophrenia184, and, among young homeless people, a high rate of attempted suicide187.

In addition to their higher risk of mental health problems, people who are single and homeless have a higher prevalence of bronchitis, tuberculosis, arthritis, skin diseases, infections, problems related to alcohol and substance misuse, and higher rates of hospital admission188-190. People living in temporary accommodation of the bed and breakfast kind have high rates of some infections and skin conditions and children have high rates of accidents191-195. Living in such conditions engenders stress in the parents and impairs normal child development through lack of space for safe play and exploration192. Whilst cause and effect are hard to determine, at the very least homelessness prevents the resolution of associated health problems. For example: many young people recently made homeless do not have adequate access to health care191; and homeless people who are heavy drinkers may have less access to health services for all their needs, including treatment of health problems related to alcohol and substance misuse196-199.

Availability of housing is related both to the quantity and quality of housing. The quality of the housing stock in Britain has steadily improved over this century but has been relatively stable since 1991. An estimated 1.5 million (7.5 per cent) homes are "unfit", a similar number to that in 199150. Estimates of the additional social, rental or "affordable" housing required varies according to the factors taken into account when making predictions. For England, typical figures have been for 90,000 to 100,000 homes per year, although some estimates are lower. However, most research indicates a considerable deficit in such housing production at present200,201. Taken together with the plateau in the number of homes which are unfit, it is likely that present housing conditions will not improve over the next five years, and may worsen.

Neighbourhoods and the development of new residential areas may benefit from the principle of planning to promote a mix of housing tenures, employment status, household composition and age groups. This may avoid the problems of concentration and isolation of those suffering the greatest disadvantages182,202-205, and the consequent overload on services.

Benefit
Although improvements in quantity and quality of housing are not certain to improve health, it is logical that they should do so. Such benefits would be on a range of health outcomes. Reducing official and unofficial homelessness would meet a basic health need of groups already vulnerable to poverty and ill-health, including families and mentally ill young people. If improvements are made through community-led development, this may also enhance social networks, with other potential benefits to health206,207.

10. We RECOMMEND policies which improve the availability of social housing for the less well off within a framework of environmental improvement, planning and design which takes into account social networks, and access to goods and services.

11. We RECOMMEND policies which improve housing provision and access to health care for both officially and unofficially homeless people.

Improving the quality of housing

Inequality
Properties in bad condition are occupied disproportionately by single older people208. Minority ethnic groups are generally more likely to be living in poor housing than the white majority209.

Forty per cent of all fatal accidents happen in the home208. Almost half of all accidents to children are associated with architectural features in and around the home210. Households in disadvantaged circumstances are likely to be the worst affected by such accidents194. Those living in high rise buildings, frequently those in lower socioeconomic groups, are more prone to serious accidents, such as falls208. Families living in temporary accommodation are also likely to suffer accidents in the home195.

Evidence
Poor quality housing is associated with poor health211,212. Dampness is associated with increased prevalence of allergic and inflammatory lung diseases, such as asthma, independent of smoking and socioeconomic factors212-214. Unmodernised older properties have far higher heating costs than improved and modern homes208. A survey of older people in 1988 found that 25 per cent were using less heat than they wished, because of the cost97. Cold housing leads directly to hypothermia and may contribute to the excess of winter deaths seen in older people208,215. It also leads to "fuel poverty"96. Whilst the hazards of such poverty could be addressed by increasing the financial resources available to older people and others living on state benefits, a more direct approach would be to improve the energy efficiency, insulation and heating systems of affected housing. Mechanisms to do this include further development of building regulations for new and existing buildings and through further development of Government schemes which subsidise improvements in existing properties. Current Government schemes, for example, the Home Energy Efficiency Scheme, may not reach homes most in need, such as the private rented sector.

Temporary accommodation tends to be ill-designed, ill-equipped and ill-maintained. Poor housing design, for instance changes in floor levels at door thresholds, contributes to seemingly minor accidents in older people, which may have grave consequences208. Disabled people are under-represented amongst owner occupiers, and rely heavily on local authority housing, especially for accessible dwellings. The stock of accessible housing is insufficient to meet the needs of disabled people, particularly for those using wheelchairs216-218.

Smoke alarms are effective in reducing deaths from fire219. The use of smoke alarms, mostly battery operated, has increased in recent years but those most at risk, e.g. living in temporary accommodation, are least likely to have an alarm where they live50. Options to promote the use of smoke alarms include placing a duty of care on landlords to install and maintain smoke alarms and including them in fitness standards for existing buildings. Removal of other accident hazards in the home might also be achieved by changes to regulations and fitness standards.

Benefit
Improvement in energy efficiency in homes is likely to improve the health of occupants, both directly and by releasing their financial resources for other uses. It also has wider benefits in conserving energy. Removal of hazards in homes is likely to lead directly to reduced death and injury from accidents. Improvements in home design might allow disabled and older people to be cared for at home, with improvements in their quality of life.

12. We RECOMMEND policies which aim to improve the quality of housing. Specifically:

12.1 we recommend policies to improve insulation and heating systems in new and existing buildings in order to further reduce the prevalence of fuel poverty.

12.2 We recommend amending housing and licensing conditions and housing regulations on space and amenity to reduce accidents in the home, including measures to promote the installation of smoke detectors in existing homes.

Reducing the fear of crime and violence

Inequality
Crime and fear of crime can affect profoundly the quality of people's lives. Just over half of the 4 million incidents of contact crime - wounding, robbery and common assault - counted by the British Crime Survey in 1995 involved injury to the victim, usually bruising and scratches. Serious physical injury is rare. But anger, shock, fear and a sense of invasion of privacy are felt by many victims220.

Not everyone is at equal risk of becoming a victim of crime. Young men, as well as being the most common perpetrators of crime, are also the most likely victims of street crime, especially physical assaults. Older people, especially women, are more likely to be victims of theft from the person. Crime tends to be concentrated in areas of social deprivation. Other indicators, such as the incidence of vandalism, graffiti, nuisance and substance misuse, are associated with levels of crime and can thus be useful markers of people's experience of crime, much of which is never reported to the police221. People from minority ethnic groups are at a greater risk of violent crime and of racial harassment66,222.

Fear of crime can also be a cause of mental distress and social exclusion. In particular, women and older people tend to worry more about becoming victims and this may prevent them from engaging in social activities. People's fear of being a victim of crime may be well in excess of the actual risks. The British Crime Survey found that 4 per cent of men, aged over 16 years, and 18 per cent of women felt very unsafe walking in the area near their home at night. These figures increased to 8 per cent for men and 31 per cent for women if only people over the age of 60 years were considered, and were considerably higher if lesser degrees of concern about safety were included. Furthermore, 1 per cent of men and 4 per cent of women felt very unsafe in their own homes if alone and at night220.

People who suffer from poor health are more likely to be victims of crime than those in good health. However, this may be because of the association of disadvantage with both victimisation and poor health, rather than poor health causing victimisation220.

Evidence
There is increasing evidence to suggest that society level factors, and poverty and income inequality in particular, may be important underlying causes of crime223,224. Studies have described how widening income inequalities in countries like Britain and the US have been accompanied by a greater spatial separation of rich and poor202. This has led to a search for mechanisms which might explain the observed relationship between income inequality and its associated residential concentrations of poverty and affluence, on the one hand, and crime on the other. One hypothesis is that income inequality is related to crime via a depletion in social cohesion, as measured by high levels of mutual distrust and low levels of reciprocity between people living in the same neighbourhood, region, or society224-226.

Although the evidence is incomplete, the link between income inequality, social cohesion and crime has important policy implications. It suggests that crime prevention strategies which only target the perpetrators and victims of crime and the high crime areas in which both groups live, will not achieve a significant reduction in crime unless they are accompanied by measures to reduce income inequality and promote social cohesion224,226.

The most effective approaches to crime prevention are likely to be those which are integrated with wider social and economic policies for reducing health inequalities. In particular, pre-school education has been shown to have a long term effect on the incidence of criminal behaviour in early adult life113,115. Similarly, measures that address the welfare needs of young people are likely to have an impact on the incidence of youth crime227.

There are a number of other measures which can help to protect local communities from high rates of crime and help people feel more secure. These measures include modifying the physical environment in such a way that crime is less likely to occur - for example, street lighting, changing the design, layout and landscaping of buildings; providing better surveillance - for instance concierge schemes, use of CCTV cameras and security alarms; and involving local police in "community policing", where officers spend more time on the beat, are proactive in identifying problems, and form partnerships with local people, businesses and other agencies. In this way, the expertise, knowledge and resources of local communities are used in helping to define, target and resolve problems228.

Benefit
It is beyond the scope of this Inquiry to recommend particular approaches to prevent or reduce crime. However, there appears to be good evidence that crime and fear of crime is felt disproportionately by disadvantaged groups and that "upstream" policies, such as pre-school education, can reduce criminal behaviour in adolescence. There is also a general consensus that crime can be prevented through targeted policing and by involving local communities which itself may promote social cohesion228. However the relative benefits of different measures, including social and economic regeneration programmes and greater provision of services for young people, are not known.

13. We RECOMMEND the development of policies to reduce the fear of crime and violence, and to create a safe environment for people to live in.

We recommend policies which will further reduce income inequalities, and improve the living standards of households in receipt of social security benefits (recommendation 3).