We consider ‘meaningful occupation’ rather than the more restrictive term ‘work’ in the sense of paid employment being central to human existence and the value of individuals in society. In a study of unemployment, the importance of work was expressed by Clarke (1982) in the following terms:

Clarke (1982) developed eight functions of work, which he hypothesizes are the reasons why people continue to work, most of which overlap with those of other writers (Cantrell 1997, Hayes and Nutman 1981). The functions of work are compared in Table 8.1 for all authors together with an indication of whether or not these values might apply to unpaid work such as hobbies, interests, or even work within the voluntary sector. One can infer therefore that there is a significant basis for regarding occupation as providing an individual with much more than just income. It is appreciated that these studies are dated but they are at the level more easily comparable with community health practice compared to the more modern meaning of the work research paradigm. Money is not the only result of work. Cantrell (1997: 115) cites Cox (1966) who states that a job is:

From Table 8.1 it is obvious that income is a major component in the decision to continue in difficult and demanding jobs. Despite this, some paid employment may result in less income than would otherwise have been obtained from welfare benefit and workers affected by these factors are less well off than those out of work. The poverty trap may well apply to people with disabilities, who may obtain more from welfare benefits than from the jobs for which they usefully aspire. Clarke (1982) reviewed the history of the Calvinist work ethic as well as the stigmatization of the unemployed which took place in historical Roman, Elizabethan and Hebrew society. Those in regular employment seemed to be favoured by social standards and even public opinion. Job satisfaction is often derived from an individual’s usefulness to other people, particularly if there is praise or gratitude. The gratitude of patients or colleagues is an obvious example for the healthcare professions.

Employment contributes identity to an individual. A new job for a young person is the reason to stop being a child. It is the sign of having a place in society, having gained the right to be an adult and gain the respect that goes with it. In the middle years, social introductions, say at a party, are frequently based on occupation rather than personal qualities. A professional or identifiable work label means more than whether the individual is doing a useful piece of work.

Status is accorded to those with a widely recognized label rather than to those who care for others. There is very little status in being unemployed, disabled or a housewife, as unjustifiable as that might be. A job can become overwhelming in our cash-limited society but nonetheless provides structure to one’s day. Apart from the decision to go to work, each day, one deals with timetables, deadlines, expectations, work schedules and many forms of public or financial accountability that fill the day. For those not in an occupation, retired or severely disabled, the absence of this structure leads to apathy and boredom. Inability to continue in employment, having to rely on charity or needing physical help from other people becomes discouraging and even demotivating. Welfare may pay some of the bills but individuals may be denied any feeling of being valuable. On retirement, people lose their social contact at work, as they cease to be one of the crowd. They adapt by joining sports clubs, churches or interest groups. For many, premature retirement is very much worse, especially if combined with poor mobility, pain, speech defects or deafness.

The employed may belong to work-related groups that may have some influence on local or national decisions such as a union or employers’ organization. Even if there are obvious power brokers in finance, politics or military systems, a place in a professional body or an industry or a union does allow participation in public debate. The unemployed have no such voice except perhaps associated with violence, emanating from boredom or the alcoholism of despair. Smith (1987) states how the loss of a job has been associated with apathy, depression and ill health and has been extensively studied. For instance, the effects of anticipated loss of work some two years ahead in a Calne factory affected sickness absence rates among employees (Beale and Nethercott 1985).

Activity is stimulating and prevents atrophy of body or mind. Inactivity rarely produces health. Many jobs produce challenges and results and if the work objectives are met, then success. The structure of work in some professions can lead to much greater energy if there are large or small achievements. Achievement is more difficult for those who have no work. Every day can be like the last – no results, no achievement. Hours spent in study, practice, research or skills training can be valuable, especially when they lead to qualification or an end result that gives public recognition. These are examples where behaviour is fired by specific goals, public acclaim or recognition as a driving force. For those unable to see such goals, each day can be grey pools of ‘sameness’, ‘uniformity’ and loss of self-respect.

Regular earners have more choice over what they can do or buy than do those in poverty. Purchasing power cannot be ignored in a society subject to great variations in finance, noticeable for those who have to live on pensions, welfare benefits or charity. Choice is reduced if financial reduction is associated with the expensive needs of being disabled and being short of transport, independence and lifestyle options. Isolation may be the only choice for those short of money. A wide range of health problems is associated with unemployment, particularly depression, high suicide rate, obesity, heart disease, smoking-related diseases and cancer (Beale and Nethercott 1985). However, studies need to resolve whether less healthy people are more likely to lose their jobs, or whether ill health is the result of loss of employment in otherwise fit people. The study in Calne is significant. Factory closure was the result of economic failure and affected a whole village population. Morbidity started to rise as soon as the closure was announced even though the actual event was not to occur for two years (Jahoda 1982).

The impact of health in the workplace depends on the nature of work and society’s economic development. The UK is termed a post-industrial society and to understand the relationship between health and work it is important to place this concept into context (Bell 1973).

Throughout the last century, there have been a number of demographic changes in the workforce, all of which have important implications for both clinical practice and health service planning. Male activity rates have declined, counterbalanced by a large increase in female activity rates though men still predominate over women in all age groups. However, that position is slowly being eroded. The proportion of potentially economically active men and women actually in employment has declined in parallel with the rise in unemployment. The decline in male rates of economic activity is due to the increasing propensity to stay in full-time education as well as for early retirement.

Explanations for the increase in female economic activity rates have included a change in the perception of women working, an increase in the availability of part-time, key-time and flexible working arrangements, and an increase in the participation of married women and women with children in the labour force. The total population and that in employment has aged, suggesting that health-related issues such as functional capacity, age and ageing will become critical in the future. The patterns of employment have also changed and affected the demand for labour. There has been a dramatic fall in manufacturing, extractive and mining industries with an expansion in service sector employment. There has also been a move from manual to non-manual occupations as well as an increase in part-time working for both men and women. This has been accompanied by a rise in self-employment and an increase in shift working, the latter being due to growth in medical advances (for the NHS workforce in particular) and increased reliance on expensive plant requiring 24/7 operation in order to recoup costs.

So what have been the consequences of such demographic change? The loss of the mining, manufacturing and construction sectors, where accident and injury rates were highest, may produce a positive improvement in health and safety but this is unlikely in the short term. Many diseases have a long latent period between exposure to the cause of the disease and the development of the disease, e.g. cancer after exposure to a carcinogen. So the employee exposed to crocidolite asbestos has an increased chance of developing mesothelioma, a type of tumour, after a lapse of 10 to 20 years. As awareness of the link between health and occupation grows, reporting might also increase, thus further offsetting the downward trend. Diseases with shorter rather than longer latent periods are more likely to improve.

The profile and nature of the risk facing the workforce is evolving with changes in the configuration of industry and occupation because of growth in numbers of women and older people in the workforce. Slips, trips and falls, especially on the same level, affect both sexes and all types of industry and occupation. They are on the increase. The shift to non-manual occupations may bring with it new health-related problems arising from new technology, new types of working environment, such as computers, air conditioning units or increased stress, or the expansion of flexible working arrangements.

In occupational health, the terms hazard and risk are commonly referred to and used in everyday practice. Unfortunately, the meanings attached to them do not correspond with the dictionary definitions. Nonetheless a clear understanding is essential to the integrity of clinical practice and decision-making. Hazard is to be understood as the potential to do harm whereas risk is to be perceived as the likelihood of such harm materializing. Any discussion of risk is usually carried out in defined circumstances and is often qualified by some statement of the severity of harm. If comparing risk between two groups of people, subject to all factors being equal, then the risk will be proportional to the hazard. However, relevant factors are very rarely equal and so it is important that they should not be considered as identical unless specifically proven satisfactorily.