Unemployment and health: the healthcare system's role

Introduction

Experience gained in addressing other health-related problems with their roots in our social and economic environments (eg, road injury or the health of indigenous people) suggests that action will be needed at many levels both within and outside the healthcare system. Healthcare provided for unemployed people should:

• Adequately address their existing health problems;
• Focus on prevention and anticipatory care; and
• Ensure that health problems do not act as barriers to a return to work.

It will also involve work with other sectors and community groups to meet the needs of unemployed people in the local community and to bring the high social and economic costs of the detrimental effects of unemployment on health to the attention of government and the community.

Here we examine possible practical action that can be taken by mainstream health services to reduce the impact of unemployment on health.

GPs' experience of the health impact of unemployment

Differences in management by GPs have been found between employed and unemployed people; people who are unemployed are more likely to be prescribed medication for depression and anxiety by GPs, and to be less frequently referred to self-help groups.⁶

Opportunities for action

Thus, up to now, the focus has been on defining the association between unemployment and health and little attention has been paid to developing or evaluating interventions within the healthcare system to prevent or reduce the health impacts of unemployment. We currently have little understanding of what are the most appropriate responses. We need more thorough evaluation of current strategies within the healthcare system for addressing this issue, and opportunities to study successful interventions in similar health-related areas.^11,12

Possible strategies are listed in Box 1 and described below.

Providing accessible preventive care and management of health problems

In the South Western Sydney Area Health Service, we have developed standards for GP management of the health problems of unemployed people. In the process, a high level of agreement was found between unemployed people, community groups and GPs on the possible role for primary care workers. GPs were seen as having a central role in providing comprehensive management of existing health problems and anticipatory care, building the capacity of their patients to solve health-related problems and ensuring referral to relevant services (Box 2). GPs trained in these standards have gained confidence in managing the problems of their unemployed patients, and increased their knowledge of local services.¹³ Further work on assessing the impact of use of the standards on patient health outcomes is required.

Patients with chronic health problems require particular attention, as these problems may lead to unemployment or act as significant barriers to re-employment. The job security of people who are limited by mental or physical conditions is increasingly at risk as the labour force contracts, and stressful working conditions may exacerbate existing disabilities, especially mental disability.

Building the capacity of the healthcare system to address unemployment

Healthcare services must be accessible and affordable. Medicare has improved access to general practice, but access of unemployed people to healthcare may be limited by the costs of private medical treatment, imaging and prescriptions. For example, people who are unemployed are more likely to experience mental health problems.^14,15 The cost of private psychiatric services is high and publicly funded mental health services may give low priority to problems such as anxiety, depression, emotional instability and social isolation, to which unemployed people are more prone. Furthermore, more unemployed people live in geographic areas where public health services are in limited supply (such as the western suburbs of Sydney and Melbourne, and in rural areas).

An ever-present problem is that even healthcare workers are not immune to prejudices against unemployed people. This can result in a lack of sensitivity to the range of problems faced by unemployed people and how they can be addressed, different medical treatment being given to unemployed people, and unjust assumptions being made ("all they want is a quick fix"). One way to deal with these prejudices is by providing pre-service educational programs that require medical, nursing and allied health students to undertake case studies of the health and social problems faced by unemployed people.

Working with other agencies and departments to reduce the impact of unemployment on health and increase the chances of finding work

Many healthcare workers already informally collaborate with other services to address the needs of particular individuals or families. A more formal and systematic collaboration is needed to prevent job loss whenever possible, to reduce the impact of unemployment on health, and to ensure that existing health problems do not become a barrier to returning to work. Establishing better relationships between service providers can prevent the different ways organisations do business from compounding the problems (eg, making arrangements for managing drug or alcohol dependence can improve unemployed people's ability to concentrate on training programs).

Action can also be directed at providing skills and resources to other organisations, and supporting them in addressing the needs of their unemployed clients. Skillshares (community-based training providers for unemployed people) provide an important venue for health service providers to make contact with unemployed people. The Division of General Practice Southern Tasmania has developed an innovative program in which GPs regularly provide health education for Skillshare participants.¹⁶ At evaluation of this program, both the confidence of participants in dealing with the health system and their knowledge of factors that improve health were increased.

Several recent studies have found that introduction of short courses to improve problem-solving skills and reduce negative feelings and beliefs had positive and long-lasting impacts on psychological health, and also increased the number of people who found work.^10,17 With experience gained from these projects, the South Western Sydney Area Health Service is working with Skillshares to promote early detection and referral of health problems, to increase the skills and knowledge of participants in making healthy life choices, and to build psychological resilience and coping strategies.

Acting as advocates for unemployed people to government and the wider community

Health workers have an important role in advocating on behalf of their patients. For people who are unemployed, this may involve intervening in decisions that have been made by government departments (eg, loss of benefits), dealing with other institutions (eg, negotiating for a priority housing listing), or asking for special support and assistance (eg, requesting assistance with paying electricity bills).

More generally, the healthcare system can highlight the impact of unemployment on health and challenge stereotyping of unemployed people as lazy or "dole bludgers".

It is in this area that the role of the health sector in preventing health problems can be most effective. Because appreciable changes in employment opportunities in Australia require political action, it is important that the contribution is not only in defining the problem but also in providing leadership in directing change.

Continuing to research the impact of unemployment on health and to evaluate interventions

There is a need for further research to explain the nature of the link between unemployment and ill-health -- the complex interplay of poverty, stress, social support, lifestyle risk factors, pre-existing disease and access to or use of healthcare services. There also needs to be a substantial shift away from defining the problem to developing and evaluating interventions that may reduce the health impact of unemployment.

At a policy level the health costs associated with unemployment need to be better documented; in part to justify the reorienting of healthcare services to address the needs of unemployed people, but also to ensure that these costs are added into any evaluation of unemployment costs to the community.

Providing training, work experience and employment for unemployed people

The healthcare system is one of Australia's largest employers. Many NSW health services have made significant contributions to providing training, work experience and ultimately employment for local unemployed people. The second-largest employer in south-west Sydney, the South Western Sydney Area Health Service (SWSAHS), in collaboration with the federal Department of Employment, Education, Training and Youth Affairs, has established both training programs for long term unemployed, and a routine referral system to the Commonwealth Employment Service for SWSAHS job vacancies in certain areas (eg, clerical and catering, as well as laboratory technicians and ward orderlies). This has resulted in over 100 unemployed people being placed in the Area Health Service. The benefits of such programs lie not only in the employment and training opportunities that they provide, but also in building up organisational commitment to addressing the health problems of unemployed people.¹⁸

Conclusion

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