How do we manage patients who become unemployed?

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

• lifestyle and risk behaviours;

• social and economic resources; and

• psychological status.

There is also a reverse effect — people with chronic illness and disability may be excluded from employment.

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:

• the common health problems that unemployed patients present with, and how these are managed;

• organising care to support this; and

• implications for policy and programs.

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;

• Money;

• Security;

• Contact with others; and

• A valued place in society.

Unemployment reduces self-esteem, probably mainly as a result of financial hardship, the loss of psychosocial resources and the loss of a sense of mastery in daily activities.9,19

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

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.

2 The 5As for managing unemployed patients in primary care29