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Sick Note: A History of the British Welfare State
Sick Note shows how the question of 'who is really sick?' has never been straightforward and will continue to perplex the British state.
Sick Note is a history of how the British state asked, 'who is really sick?' Tracing medical certification for absence from work from 1948 to 2010, Gareth Millward shows that doctors, employers, employees, politicians, media commentators, and citizens concerned themselves with measuring sickness. At various times, each understood that a signed note from a doctor was not enough to 'prove' whether someone was really sick. Yet, with no better alternative on offer, the sick note survived in practice and in the popular imagination - just like the welfare state itself.
Sick Note reveals the interplay between medical, employment, and social security policy. The physical note became an integral part of working and living in Britain, while the term 'sick note' was often deployed rhetorically as a mocking nickname or symbol of Britain's economic and political troubles. Using government policy documents, popular media, internet archives, and contemporary research, Millward covers the evolution of medical certification and the welfare state since the Second World War, demonstrating how sickness and disability policies responded to demographic and economic changes - though not always satisfactorily for administrators or claimants. Moreover, despite the creation of 'the fit note' in 2010, the idea of 'the sick note' has remained. With the specific challenges posed by the global pandemic in the early 2020s, Sick Note shows how the question of 'who is really sick?' has never been straightforward and will continue to perplex the British state.
Sick Note is a history of how the British state asked, 'who is really sick?' Tracing medical certification for absence from work from 1948 to 2010, Gareth Millward shows that doctors, employers, employees, politicians, media commentators, and citizens concerned themselves with measuring sickness. At various times, each understood that a signed note from a doctor was not enough to 'prove' whether someone was really sick. Yet, with no better alternative on offer, the sick note survived in practice and in the popular imagination - just like the welfare state itself.
Sick Note reveals the interplay between medical, employment, and social security policy. The physical note became an integral part of working and living in Britain, while the term 'sick note' was often deployed rhetorically as a mocking nickname or symbol of Britain's economic and political troubles. Using government policy documents, popular media, internet archives, and contemporary research, Millward covers the evolution of medical certification and the welfare state since the Second World War, demonstrating how sickness and disability policies responded to demographic and economic changes - though not always satisfactorily for administrators or claimants. Moreover, despite the creation of 'the fit note' in 2010, the idea of 'the sick note' has remained. With the specific challenges posed by the global pandemic in the early 2020s, Sick Note shows how the question of 'who is really sick?' has never been straightforward and will continue to perplex the British state.
246 pages, Hardcover
Published December 8, 2022
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November 1, 2024
Really good history of (mainly short-term) sickness benefit policy since WWII. Doing a long review so I can remember favourite bits in the future.
It was particularly good at describing the prevailing views of culture throughout the time period, showing that similar views about absenteeism have been around since the start of the postwar period (as usual with history, perceptions of problems and required solutions are not new but have been identified again and again).
Also raises really good points about changes to the labour market, with the move away from stable long-term employment towards self-employment and other flexible working patterns adding pressure to the short-term sickness infrastructure (SSP in its current state is being rendered even less effective).
Great on the ‘using a hammer when you need a scalpel’ problem of past policy on incapacity benefits and capability testing. I was struck by the example of Waddell and Burton’s review of the benefits of work, which found that good work (suitable for the employee) was good for health and wellbeing but bad work detrimental, and yet led to a system that implicitly said ‘all work’ was good for health and tried to push unemployed and incapacity claimants into any available work rather than trying hard to find suitable jobs. Capturing nuance is so important in good policy and yet very hard in practice.
Lastly, the detail on widespread fears around self-certification and its implementation, along with the gradual privatisation of short-term sickness costs in the 80s and 90s, was a really good case study for policy that showed fears around malingering and scrounging under these reforms (at least for short-term sickness) were much greater than they proved in reality.
I would have appreciated a bit more detail on medium/longer-term sickness, especially given its importance in the post-covid labour market and welfare state. I also would have appreciated it being a bit more readable at times (but maybe that reflects more on me than on the author). My biggest criticism would be the absence of any solution for the glaring problem of how to draw boundaries between sickness and health/capacity and incapacity/deserving and undeserving, which while very difficult is a necessity in the current welfare state. Rather than providing an alternative vision for how to support those with sickness, it leaves you feeling flat, concluding that the current system is very bad but there is little hope of a better one. Perhaps looking at different examples from Europe of sickness and disability benefits that have alternatives to testing would have helped - but then again, that is going beyond the scope of the book.
It was particularly good at describing the prevailing views of culture throughout the time period, showing that similar views about absenteeism have been around since the start of the postwar period (as usual with history, perceptions of problems and required solutions are not new but have been identified again and again).
Also raises really good points about changes to the labour market, with the move away from stable long-term employment towards self-employment and other flexible working patterns adding pressure to the short-term sickness infrastructure (SSP in its current state is being rendered even less effective).
Great on the ‘using a hammer when you need a scalpel’ problem of past policy on incapacity benefits and capability testing. I was struck by the example of Waddell and Burton’s review of the benefits of work, which found that good work (suitable for the employee) was good for health and wellbeing but bad work detrimental, and yet led to a system that implicitly said ‘all work’ was good for health and tried to push unemployed and incapacity claimants into any available work rather than trying hard to find suitable jobs. Capturing nuance is so important in good policy and yet very hard in practice.
Lastly, the detail on widespread fears around self-certification and its implementation, along with the gradual privatisation of short-term sickness costs in the 80s and 90s, was a really good case study for policy that showed fears around malingering and scrounging under these reforms (at least for short-term sickness) were much greater than they proved in reality.
I would have appreciated a bit more detail on medium/longer-term sickness, especially given its importance in the post-covid labour market and welfare state. I also would have appreciated it being a bit more readable at times (but maybe that reflects more on me than on the author). My biggest criticism would be the absence of any solution for the glaring problem of how to draw boundaries between sickness and health/capacity and incapacity/deserving and undeserving, which while very difficult is a necessity in the current welfare state. Rather than providing an alternative vision for how to support those with sickness, it leaves you feeling flat, concluding that the current system is very bad but there is little hope of a better one. Perhaps looking at different examples from Europe of sickness and disability benefits that have alternatives to testing would have helped - but then again, that is going beyond the scope of the book.
Displaying 1 of 1 review