The number of unemployed patients presenting in general practice will increase over the next 12 months.
Unemployed patients are likely to present with physical and psychological problems, including insomnia, depression, anxiety and a worsening of cardiovascular risk factors; family members are also likely to be affected.
GPs have an important role in early detection and management of these health problems; effective approaches include cognitive behaviour techniques, goal-setting and motivational counselling.
Appropriate provision of medical certificates, advocacy and social support help redress the loss of the personal and social “vitamins” of work.
While access to psychological services has improved, patients may also need to be referred to social workers, and employment and welfare services.
Divisions of General Practice can have an important role in helping to broker access to services and raise awareness of the health effects of unemployment.
In men who had been continuously employed for at least 5 years in the late 1970s, mortality doubled in the 5 years after redundancy for those who were aged 40–59 years in 1980.1 Now, after a period of relatively full employment, we face rising unemployment in response to the global financial crisis. It is estimated that unemployment may reach 6%, with as many as 600 000 Australians possibly losing their jobs in 2009 and 2010.2 Work has become increasingly precarious, with many people cycling between insecure employment and unemployment, and an increasing number of under-employed people. The health effects of this precarious situation may occur across the gradient from the full-time employed to the long-term unemployed.3 This will have direct and indirect effects on the population, and these effects will be expressed in presentations to primary health care services. While the health system itself may have limited ability to address unemployment, it can act to minimise the long-term effects on health by ensuring adequate physical and mental health care, and arranging social support.
The link between unemployment and ill health is well established. Unemployed people are more likely to have higher rates of cardiovascular disease, respiratory disease, intentional and unintentional injury, anxiety and depression, and higher rates of death from these, than those who are employed.4-7 Although ill health associated with unemployment is more common in men than women,4 the gap has been closing since the 1970s. There are also higher rates of insomnia and risk factors for psychological and physiological disorders among people who are unemployed.8 These problems can become manifest before people actually become unemployed, during periods of job insecurity, and can continue until they are re-employed.3
The mechanisms for these associations are complex and include the effects of unemployment on:9
Unemployed people are likely to use primary health care services more than those who are employed.10 However, this use is often reactive, with unemployment often being a barrier to preventive care, and unemployed patients being less likely to be referred to self-help groups.11-13 There has been little research on the effectiveness of interventions for unemployed people and their families, especially in relation to their physical health, within primary health care settings.
In this article, we describe an approach to providing health care for unemployed people based on the limited direct evidence available, and on extrapolation from other evidence about best practice for providing health care for disadvantaged groups. We will describe:
Two of the most significant studies of the impact of factory closures on health were undertaken by general practitioners — one in Denmark and the other in England.14,15 These showed that retrenched workers had higher rates of illness and disability resulting from a range of long-term conditions, including psychological, cardiovascular and respiratory disorders. Our own research has confirmed this in Australian general practice.16 Families of people who are unemployed may also be affected, especially by interpersonal violence and poverty.17
Loss of work can lead to social isolation and feelings of being excluded from the wider society. Work fulfils many functions apart from providing an income. Warr has identified what he calls “the nine vitamins of work” that need to be supplemented during periods of employment to ensure wellbeing during periods of unemployment.18 These are:
Opportunity for control over aspects of work;
Opportunity to use and develop skills;
Being able to work with others on common goals;
Variety in daily activity;
Feedback from others on current and future activities and plans;
Contact with others; and
A valued place in society.
Primary health care providers can influence the likelihood of their patients’ return to work and recovery by treating unemployed patients with respect, and explaining their condition and treatment in an understandable way.20 Many unemployed people report that their health problems are dismissed as being related to stress and are not taken seriously by health professionals.21
Unemployed patients are more likely than employed patients to present with or be diagnosed with anxiety, depression and sleep disorders.7,8 Some patients, especially those from Asian cultural and ethnic backgrounds, present with somatisation of psychological distress.22 While depression or anxiety is likely to result in more health interventions in unemployed patients, the effect of these interventions does not always have a positive outcome in terms of likelihood of the patient returning to work.23 We found in the 1990s that GPs were more likely to prescribe and less likely to offer non-pharmacological interventions for unemployed patients with depression or anxiety (presumably because of cost and availability barriers).7 Patients with depression in primary care who are unemployed are less likely to achieve remission of their depression.24
However, it is important not to succumb to therapeutic nihilism. Cognitive behaviour techniques are effective in improving psychological health and promoting re-employment among unemployed people.25 GPs may be able to apply some of these (eg, problem solving) in the context of routine consultations, and refer patients to a psychologist for more intensive interventions. Anxiety and depression can also make it difficult for people to put structure in their day and make decisions. Simple advice on how to structure their day may be useful in managing patients’ feelings of powerlessness and hopelessness. We present a case study in Box 1, illustrating the presentation of an unemployed patient to a GP, and subsequent management.
Unemployed people are more likely to have individual behavioural risk factors, including overweight, smoking and poor diet, than those in employment.26 They are also more prone to physiological cardiovascular risk factors such as hypertension and dyslipidaemia.8
It is often assumed that, given the other stressors in their lives, expecting people who are unemployed to make significant changes in behaviour is unrealistic. However, given that risk factors like smoking are most likely to have a long-term impact on their health, it is important that patients are informed and offered interventions. A recent systematic review reported success with interventions for smoking cessation and healthy eating in disadvantaged patients.27 Nicotine replacement therapy appears equally effective for smoking cessation in disadvantaged groups.
Providing information, setting goals for change, and motivational counselling are key strategies for providing effective preventive care to unemployed patients.28 The “5As” framework provides a basis for delivering these in primary health care (Box 2).29 Again, there is good evidence that the 5As framework is effective for delivering health behavioural risk factor interventions, and it is important not to assume that interventions will fail or are inappropriate because of all the other stressors that confront unemployed patients.
Patients who are unemployed may present for certification either of their fitness for work or their incapacity to allow them to seek jobs. Injury and disability have significant effects on future employability. These medical certificates can determine the type and level of government assistance that people receive, as well as their entitlements for rehabilitation and training programs and, thus, return to work. There may be a tension between certifying someone unfit for job-seeking due to illness resulting from their unemployment, and the risks that long-term unemployment poses. It is important to discuss this in a positive way (eg,“It is important for you to feel up to job seeking, and you need some time off, but not for long as re-employment is our major goal”). This can be time-consuming and, like other forms of social advocacy for patients (with Centrelink, employers, housing, financial institutions, etc), it is not remunerated. Most people find work through informal networks. Many GPs have strong links with their communities and know where emerging employment can be found. In our previous work, we found many examples of GPs linking patients with employers.
It is important that employment status is ascertained sensitively as a routine part of booking in and history-taking by the GP or practice nurse, and noted in the medical record. For the clinician, the way in which the patient responds to this question may provide useful information about how to approach the issue and about the patient’s response to their status.
Strategies that have been shown to be useful with disadvantaged groups include outreach services, reducing cost and other barriers to access, developing culturally appropriate services, and increasing access to skills and resources that will enable patients to adopt more health-promoting lifestyles.27 A number of Divisions of General Practice have developed programs that attempt to improve access for socioeconomically disadvantaged groups through direct provision of allied health services and raising community awareness of the need to access GPs for preventive care. Targeted community-based preventive or outreach programs are effective in reducing behavioural risk factors and improving preventive health care.30 Divisions may also play a role in linking unemployed people to employment and welfare services and helping to establish support groups for people who are unemployed.
Cost is an important barrier to care. There is, therefore, a role for advocacy, even within the health care system — such as trying to find medical specialists who will bulk-bill disadvantaged patients. Fortunately, referral to a psychologist is easier for patients who have an assessed mental disorder under a GP mental health plan (see http://www.psychology.org.au/Assets/Files/Medicare-Supplement-MBS-July08.pdf). However, many psychologists charge copayments on top of this, making it still unaffordable for unemployed people.
Links to the social welfare system are important, especially links to organisations that provide financial counselling, financial support, training and rehabilitation services. Few GPs have a good understanding of the welfare system, or have the time to negotiate the right service for their patients. Social workers in Centrelink offices, local council community welfare services and community health services may be useful sources of information and referral.
Auditing the records of patients who are unemployed is a useful prompt to reflection on how unemployed people are presenting to the practice, and how they are being managed — especially in relation to planned preventive care (including health checks) and referral (an example of a proforma for such patient auditing is available from the authors). Practice nurses have important potential roles in helping to provide support and education, facilitating the organisation of care, and in creating better links with other health and welfare services.
Some Divisions of General Practice have had a role in supporting practices to improve their care for unemployed patients. In the 1990s, Divisions in South Western Sydney provided practices with information on the pattern of unemployment in the local area, relevant guidelines and templates for care planning, and information about local health and welfare services for unemployed people. Others have also trained GPs to provide preventive clinics and outreach services for disadvantaged groups (eg, the St George and the Central Coast Divisions of General Practice). Divisions may also act as brokers, facilitating access for unemployed people to social welfare and employment services and programs, and facilitating communication between general practices and other services.
Since we did our work on unemployment and health in general practice in the early 1990s, there are now more options for managing unemployed patients, including access to allied health and psychological services for some patients. However, there is the need for a more proactive approach, providing early intervention for patients who are at risk of becoming, or have recently become, unemployed. This is where support and preventive interventions are likely to be most successful in achieving both health and employment outcomes. With its breadth of focus and acceptability to patients, primary health care is uniquely placed to do this.
1 Case study
G H is a 51-year-old man who has just lost his job. He had been employed as a metal worker for almost 20 years. After 4 months of uncertainty, during which overtime was restricted, the company laid off 40 workers, including G H. He has applied for several jobs, but has not had an interview.
He has a past history of back pain (a year ago) which resolved after several weeks. He does little physical activity, and smokes 10 cigarettes a day (having tried to stop last year but relapsing). His waist circumference, blood pressure, and fasting lipid levels are above target levels, and both his absolute cardiovascular and diabetes risk are high (although his fasting blood glucose level is normal).
His GP explains his risk, and it is agreed that he needs to lower his cardiovascular and diabetes risk by stopping smoking (using nicotine replacement therapy to assist) and reducing his weight by 5%. Some time is spent discussing his depression and insomnia. Suggestions are made about sleep hygiene, and trying to put structure in his day, including at least 30 minutes of physical activity. Initially, he does not want to be referred to a psychologist. However, this is discussed again at a follow-up visit with his wife, and referral for cognitive behaviour therapy was arranged as part of a mental-health care plan.
The short-term goals for this patient are management of his depression and anxiety; however, the longer-term goal is to support his return to full-time employment. The GP arranges to review his progress towards re-employment in 3 months.
2 The 5As for managing unemployed patients in primary care29
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