Ewan Macdonald: Don't just sit there doing nothing - get a life

Ill health is costing Scotland about £10bn a year. But with a welfare system designed to maximise people's potential, the figure could be slashed.

Our welfare system is a great success overall, but it fails a significant number of our people. A total of 20 per cent of our school-leavers have poor literacy and skills for work, and it is therefore no surprise that the average reading age in our prisons is nine and employers protest about controls on immigration because they cannot recruit appropriate skills here.

While life expectancy in Scotland has improved, it is still worse than England and most of the developed West. More depressingly, the gap between rich and poor has not improved, and health inequalities are such that the difference in life expectancy in adjacent parts of our cities can be well over ten years. Much of our inequalities in health and mortality are due to worklessness. Your occupation determines your social standing, prosperity and to a great extent your mortality. This effect is shown in the Scottish Index of Multiple Deprivation, where the most deprived are the workless.

Official figures show 2.6 million people in the UK (300.000 in Scotland) are apparently unfit to work, a higher proportion than in any other developed country. Only some of this is due to the "benefits trap".

In Scotland 2.1 per cent of the workforce leave the workplace through ill-health each year, and about 9 per cent receive health-related benefits. Scotland has higher rates of incapacity than England. This varies with age and geography, and so extremes exist such as Glasgow, where 30 per cent of men over 55 years of age are workless through ill-health. Every one of these individuals has been labelled as too ill to work by health professionals yet there is ample evidence that many are fit to do something.

The costs of this are colossal - Dame Carol Black's review of the health of the working population estimated that ill-health is costing the British economy 100 billion per year and in Scotland the costs are likely to be around 10bn.

Important reviews by Professor Gordon Waddell have confirmed that good work promotes health and that most work is beneficial, and that worklessness itself causes health to deteriorate. He also emphasised the importance of the cocktail of social, medical and psychological problems which people may experience and which explains why individuals with the same health condition can behave entirely differently - the so-called bio-psychosocial model of health. In these, just dealing with the health issue alone generally does not work.

So loss of a job through ill health generally makes health worse, and the social isolation can lead to a downward spiral. This affects the children of the long-term workless, and the cycle tends to repeat. But, working independently - in silos, to use the jargon - the NHS, education and social services, and the benefits system do not grasp this. That failure compounds ill-health, causes needless expense for the public purse, and locks in welfare dependency.

For the ill or injured the NHS does not yet consider returning people to employment or to maximum function as a priority. As a result, far too many people end up losing their jobs. Those at risk of doing so have no access to expert advice about alternative career options until they have become workless. A total of 50 per cent of those on health-related benefits have no educational qualifications at all and are unlikely to have had any systematic approach to improve their skills, unlike the professions.

It then becomes convenient to use health as the justification for worklessness, as most people before they retire will have some chronic health issues - but not such that it would cause them to stop work. Our population is addicted to healthcare and our system creates dependency. "I am under the doctor … I am waiting for a scan".

Many health problems are better explained by the bio-psychosocial model of health, rather than the medical model which assumes that if you have symptoms these will be solved by health professionals. Evidence for this are patients who have medically unexplained symptoms, often requiring repeated attendances and expensive investigations.

Evidence that a different approach works has been the experience of case-managed interventions for 5,500 long-term workless with health problems in NHS Lanarkshire, where only 3 per cent needed to see a doctor but 30 per cent were rehabilitated to work and 10 per cent into education.

What are the solutions? At present our welfare services tend to be delivered from silos, delivering only what they know how to deliver. Rather than attempting to change these, their focus should not be just on the individual's medical condition, their housing problem, their social problem or their educational needs, but should also ensure that in any interaction, individuals are routinely screened to identify their other needs with the aim of improving their functional capacity.

Functional capacity is our ability to do as much as possible, for as long as possible, in both our work and leisure. It is about quality and opportunity - physically, mentally, socially, and spiritually.

Importantly, it is measurable. The key ingredients are: educational attainment - the illiterate are poor and unhealthy and PhDs live the longest; effective rehabilitation, when ill or injured; healthy lifestyles; safe and healthy workplaces and communities; ready access to employability advice and modification of work for those struggling in work as well as those on benefit.

Scotland is awash with public sector-workers, but they require a common purpose. Critically, this does not require more resources.

Scotland is making good progress. We have strategies for Life Long Learning, Healthy Working Lives and a Rehabilitation Framework. The new Health Works strategy is a radical effort to extend this to all the working-age population. In March, Working Health Services Scotland, funded by Scottish Government and Department of Work and Pensions, was established to provide return-to-work rehabilitation services for the employees of small and medium enterprises for the whole of Scotland.

Other initiatives of the public sector have been the cross-cutting Equally Well, Pathways to Work, the introduction of the "fit note", and the more local Glasgow Works. But programmes do not link up, and navigating through the system is beyond most of us. There should be one point of access, and some can be accessed already via Healthy Working Lives.

The welfare state requires a single over-arching purpose - to maximise the function of the individuals it serves. No-one should be able to leave education without achieving their potential in basic literacy and numeracy and have some vocational competence, and all should be encouraged to participate in a life-long learning programme to ensure continuing skill development.

All patients of the NHS should have return to maximal function, including work if possible, as part of their care plan. Every individual should be encouraged and supported to take control of their own functional capacity, have a well-being account and be able to self assess their capacity by questionnaire, and then be able to access advice to improve through one telephone number.

The benefits of this approach would be a reduction in healthcare costs, a fitter population, lower sickness absence and reduced numbers flowing onto benefits, with advantages for individuals, communities and the country. Importantly, it will not require additional resources but just re-focusing of those that are there.

l??Professor Ewan Macdonald is head of the Healthy Working Lives Group, University of Glasgow, and director of Salus.