Public health in a recession
Once upon a time, in a land not so very far away, dinner-table conversation revolved around the price of houses and the size of mortgages.
But then the economy went sour and recession arrived. As unemployment and inflation crept up month by month, the chattering turned to a fearful whisper as people wondered how they would manage, especially if they lost their job or their home.
But this is not a fairy tale - it is what Britain faces today. While nurses probably have less reason than many to worry about their jobs, the profession will not go untouched by a long and deep recession. The effects could be far-reaching, affecting jobs, health, wealth and professional boundaries.
Already alert to the potential public health impact of a recession, 10 Downing Street has for some weeks been gathering information from eminent epidemiologists and human geographers, who specialise in mapping health inequalities.
Danny Dorling, professor of human geography at the University of Sheffield, is among them - his call to Nursing Times was cut short by a call from No 10.
'Health tends to get worse in a recession,' he says. 'The most obvious way is the effect of unemployment on health. At the extreme, it doubles the risk of suicide, depression and attempted suicide.'
'Unemployment is bad for your health,' agrees Professor Richard Wilkinson, emeritus professor of social epidemiology at the University of Nottingham medical school. It is not just that people in poor health are more likely to be unemployed, he stresses. 'The evidence from studies looking at the closure of factories is that everybody who lost their job saw their health go down regardless of how healthy they were to start with.'
Homelessness and unemployment
The mere threats of unemployment and its twin evil homelessness damage health. 'It seems to be to do with stress which, we know, has numerous physiological consequences on the cardiovascular system and the immune system,' says Professor Wilkinson. 'Sometimes people liken it to rapid ageing.'
The international evidence on the health effects of a recession is pretty much unanimous: it's a bad thing. Only two studies, both from the US, seem to contradict this. One suggests that employed people become healthier in a recession, perhaps because they reduce risk-taking behaviour such as drinking and smoking. The other shows that death rates go up in times of boom as people overwork, drink and smoke too much, and are involved in car crashes and industrial accidents.
However, the weight of evidence from studies in Japan, the US and Europe shows mortality and morbidity rise in hard times, especially for those who lose their jobs.
'Any financial crisis affects poor people the most,' says Rosalind Godson, public health lead for the CPHVA. 'We know that.'
Recessions tend to increase the distance between rich and poor, agrees Professor Dorling. He expects to see health inequalities rise further as the recession deepens. 'If the recession was one that equalised people, you get the opposite result,' he explains. 'That is what happened in wartime Britain, where the health of the population dramatically increased and everybody became happier. It is inequality that damages health.'
The recessions of the 1970s, 1980s and 1990s in Britain were not equalising, says Professor Dorling. 'The poor ended up unemployed, the middle-class people got jobs that were maybe not the ones they wanted nor paid as much as they expected.'
It is extremely hard to set out the health effects of a recession that has yet to take root. Economic commentators predict that this one will hit the service economy hardest and that the south-east will not escape as lightly as it did in the latter decades of the 20th century.
We already know that the most economically deprived communities have the poorest health, with higher rates of smoking and alcohol use, and all the consequences of this, such as increased rates of heart disease and cancer.
Professor Dorling believes rates of alcohol use, drug use and mental health problems could all rise as people lose their jobs and experience feelings of hopelessness. 'You might as well drink and smoke and take drugs,' he says by way of explanation. 'And that's what people do.'
The good news - if you can call it that - is that, in 2008, the government knows all this. Both Professors Wilkinson and Dorling agree that state intervention can lessen the worst effects.
'The government know, although they are timid about it, that they can put in place programmes to create work for young people and the lower-skilled,' says Professor Dorling. 'It is a question of whether they are brave enough to do it.'
Would the government be brave enough, say, to increase unemployment benefit - a factor known to protect the health of the unemployed? Will it allow councils to buy privately owned homes and rent them back to people in mortgage arrears rather than see them repossessed?
Given that a recession is likely to mean more health problems, how quickly would these filter through - and what would they look like?
'If you are looking at death rates, it would take some time,' says Professor Wilkinson. 'But, if you are looking at self-reported health and levels of anxiety or sleeplessness or use of psychotropic drugs, it may be much shorter.'
Mental health affected quickly
Mental health charity Rethink says mental health problems will manifest themselves quickly, with more referrals and admissions to mental health services. In October, it released a survey of 2,000 people, which highlighted the prospect of home repossession as their most pressing concern, with 46% saying it would damage their mental health.
Rethink commissioned a literature survey alongside its poll. This backed up the charity's prediction. 'The evidence is that mental health admissions went up in the last recession,' says policy officer Antonia Borneo.
'We expect to see a spectrum,' she adds. 'There will be people with low-level symptoms but it is also a dangerous time for people who are vulnerable and we can expect to see more relapses.'
Ian Hulatt, the RCN's mental health adviser, agrees with Rethink's analysis but adds: 'I think there is some good news in that we have many more creative and useful ways to access mental health services these days.'
GPs are more sensitive to mental health issues than before, he says, and access to cognitive behavioural therapy is improving. 'There are also many more self-help tools,' he adds.
Some US researchers have suggested that road traffic accidents, alcohol and drug use may go down in a recession while more people live healthily. These views do not gain much currency here.
In November, celebrity chef and food campaigner Jamie Oliver told the health select committee that unhealthy eating would probably increase in a recession. 'This is the first time in British history that we have a large number of people who cannot cook,' he said. 'If you have knowledge about how to cook, you will know how to buy efficiently and cheaply.'
The AA rejects any notion that road traffic accidents go down in a recession. 'When Norman Tebbit [secretary of state for employment during the 1981 recession] told people to get on their bikes he was telling people to go further to look for work, not to get some exercise,' says a spokesperson. 'Traffic has gone up inexorably for 30 years. If anything, accidents will go up as there may be more cyclists and pedestrians who are more vulnerable.'
Help the Aged has warned that some 50% of pensioners will not be able to heat more than one room this winter as inflation eats into their income. This will mean an increase in people with respiratory conditions presenting to GPs and at A&E.
Simon Eccles, A&E consultant at London's Homerton University Hospital NHS Foundation Trust and national clinical director for NHS Connecting for Health, expects other pressures to come to bear in A&E too.
'We are likely to see more people change job and have more industrial accidents as a result,' he says. 'We are already seeing huge numbers of people taking to bikes and scooters and we can expect them to fall off.'
Ms Godson predicts that other problems will be made manifest in the community. It will be not only older people who will be suffering the effects of fuel poverty but also families with children who have special needs, especially those whose finances are already under strain.
'Where does the extra money come from to wash and dry the sheets if your child wets the bed?' she asks. 'What about the family with a child with sickle cell? Any child who needs more resources will be a bigger stress.'
More work for the NHS
The impact of the recession on the voluntary sector is also likely to be dire - and lead to more work for the NHS.
Rachael Maskell, Unite's national officer for community and non-profit sector, says that contributions to voluntary agencies have dropped by 50% since the economic downturn, meaning many preventive services they provide have been cut.
'Advice services are seeing a 33% increase in demand for their services at a time when income is falling,' she says. 'Every£1 spent on advice saves£15 elsewhere in service provision. You can guarantee that pressure on public services will be greater and the NHS is part of that equation.'
There's no such thing as taking a 'sickie' any more, it seems, as the recession is making people reluctant even to take time off to see the doctor when they are ill.
A survey carried out in August and published in October for health insurer HSA found that 83% of workers were feeling the pinch and 42% would be less likely to take time off work as a result.
More worryingly, it found that one in five would be less likely to act on lingering health issues. HSA found evidence of people putting off trips to the dentist and ophthalmologist, again because of the cost.
HSA spokesperson Clare Lee spells it out: 'The economic slowdown is clearly leaving people less inclined to take time off work as they are worrying about keeping their jobs. And, when times are tight, the report shows that people are less willing to invest in their health.
'However, this can be costly as neglecting your health can result in illnesses worsening and even long periods of absence from work. People should take a preventive approach to healthcare.'
This is, quite possibly, good advice - but it would be foolish to take this at face value. HSA, after all, sells health insurance.
The British Dental Association was sceptical, saying it had no evidence to date of people putting off visiting the dentist - at least, no more than usual.
Nurses feeling the pinch
Trade unions say nurses are already feeling the pinch, and this was confirmed in a recent Nursing Times survey on how they are are coping with the rising cost of living. More than 25% of student nurses are dropping out of their courses, record numbers of nurses are accessing help on managing debt and house repossessions, and more are having to take second jobs to cope financially.
In October, the unions launched a joint bid to reopen pay talks. Dr Peter Carter, chief executive and general secretary of the RCN, explains: 'The current economic crisis is compounded by the fact that we have an ageing NHS workforce and increasing numbers of students dropping out of their courses. All this points to a recruitment and retention crisis right around the corner.'
But does it? The Confederation for British Industry has counter-argued that the recession may lead to people staying in jobs longer. Meanwhile, the government is working on age discrimination legislation that could see the mandatory retirement age - though not the pension age - abolished.
The Department of Health says it will be up to the NHS pay review body to decide whether a new pay deal is warranted. Its announcement is due on 15 December.
NHS Employers recently said it could not see any threat to nursing jobs - but will that last? Professor Jim Buchan, of the Faculty of Health Sciences at Queen Margaret University, looks at how the job market will play out for nurses. He believes that the immediate impact of the recession is likely to mean some nurses will want to increase their working hours, while others may re-enter the profession.
'This has happened in previous recessions - they may be in families where a partner loses their job and have to take on additional earnings responsibilities,' he says.
Professor Buchan says one likely change from previous recessions is in its geographical impact.
'Manufacturing industries were hard hit in previous recessions which meant that parts of the midlands and the north of England bore much of the brunt,' he explains. 'This time around, it will be service sector that takes the main hit, so we can anticipate that the south will not escape.'
The government has said it will stave off the worst of the recession through a programme of public funding. However, while this should help protect NHS jobs, some of the money is likely to be used on capital projects such as building and refurbishing hospitals and clinics.
Further down the line, the tax base will suffer from the downturn in the economy, and Professor Buchan believes NHS budgets will get tighter, restricting nurse recruitment. It is therefore likely that more UK nurses will look to migrate to find work, but there is no certainty that the usual destinations of Australia, New Zealand or the US will be in any better financial state.
However, it is not all bad news. Professor Buchan says that in the short term at least, the current direction of policy with the Darzi review points to more prospects for nurses in advanced roles.
'For example, NHS London is expecting a significant increase in requirements for nurses in this role as its focus shifts to primary care,' he says. 'This policy direction also flags up a big increase in the use of assistant practitioner [HCA] roles. The shape of the nursing workforce is therefore likely to change, with relatively more nurses working in advanced roles, but assistant practitioners taking on some basic nursing duties.'