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Is ill health driving economic inactivity, and what can be done? – with Sarah O’Connor and Professor James Banks Episode 26 of the Health Foundation podcast

Episode 26 |10 December 2022 |38 mins

About 1 mins to read

We're all familiar with some of the challenges ahead in the UK: a fiscal squeeze, limp productivity, a labour shortage and an ageing population with increasing needs. As Andy Haldane put it in our recent REAL Challenge lecture, two routes to prosperity for the UK include increasing the number of workers and their productivity. But both of these routes now appear to be hampered by increasing ill health. 

Since the pandemic, 600,000 working people have become economically inactive – that’s the size of the city of Manchester taken out of the economy. Two-thirds are the over 50s who've left and aren't looking for work. And at the other end of life, younger people entering work are reporting markedly more ill health due to depression and anxiety, and more young men in particular are economically inactive. 

Can we carry on like this if our economy is to recover? Or is it now time for us to get serious about these trends, and how? 

To discuss, our chief executive Dr Jennifer Dixon is joined by:

  • Sarah O’Connor, employment columnist at the Financial Times.

  • James Banks, Professor of Economics at the University of Manchester and Senior Research Fellow at the Institute for Fiscal Studies. 

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Jennifer Dixon: Today, we're talking about the rising tide of ill health amongst the working age population and whether it's causing people to drop out of the labour force and become what's called economically inactive. If so, what to do about it. We're now all familiar with some of the challenges ahead in the UK: a fiscal squeeze, limp productivity, a labour shortage and an aging population with increasing needs. As Andy Haldane put it in our recent REAL Centre Challenge Lecture, two routes to prosperity for the UK include increasing the number of workers and their productivity. But both of these roots now appear to be hampered by increasing ill health. 

Long run trends show a steady increase in long-term illness reported in the working age population of about 0.5% a year. Since the pandemic, fewer working age people are in work at 600,000 fewer, that's the size of the city of Manchester taken out of the economy. Two-thirds are the over 50s who've left and aren't looking for work. And at the other end of life, younger people entering work are reporting markedly more ill health due to depression and anxiety, and more young men in particular are economically inactive. 

So, can we carry on like this if our economy is to recover? Or is it now time for us to get serious about these trends and how? With me today, I'm delighted to welcome back to the podcast Sarah O'Connor, an award-winning Financial Times journalist who's written widely on working life, particularly for low paid workers. And she's joined by James Banks, Professor of Economics at the University of Manchester and Senior Fellow at the Institute for Fiscal Studies. And James has written on health, retirement, and employment amongst many other things. Welcome both. 

So there seem to be two trends going on here. One is the rising ill health in the working age population, sort of long run trends and then the acute to do with related to the pandemic. And then the second trend is the increasing number of people who are economically inactive. Looking at longer run trends since the financial crash, economic inactivity levels were actually reducing in that older people retired later, more women joined the workforce. But these trends have now gone into reverse so that about 22% of working age people 16-64 are economically inactive. That's a staggering proportion. And James, I wondered if you could help us a little bit more to understand these trends and what might be causing this recent uptick. 

James Banks: In terms of numbers, and partly this is because of the cohort demographics and the aging of the baby boomers, a lot of the biggest numbers of workers becoming inactive, if you like, are amongst the older workers group – 50 and over really. And because there's a lot of 50 and overs now as the inactivity rate rises, which it has done as you said essentially from around the time of the pandemic, it's been rising a small percentage rate and that can quite a lot of workers in the workforce. And of course this is, as you said, a group where ill health has been rising slowly maybe over the last 10, 12 years. But to associate the two I think is a difficult step to make. And actually when you look a little bit deeper into, if you like, the causes of the inactivity, it actually looks like the main rise, and some of my colleagues at the Institute of Fiscal Studies have been digging into this data, looks like retirement related inactivity. So people just saying they're not looking for more work because they're retiring early, they're below the state pension age. 

Some other reasons, which is a rather nebulous category, but if you actually look at the people who say they're inactive for health reasons, that's actually rather small fraction of this uptick. Typically, people who've been out of work for some time already, and maybe even before the pandemic. So this idea that somehow there's an underlying reduction in the health of the workforce that is leaving people to leave work and become inactive as a result of their health, and that's what's driving the uptick, I think that's a little bit of a stretch given what data we know at the moment. 

Of course there's going to be some element of that but I don't think that's what's been driving the numbers. Instead, it might be more like, one wouldn't really call it a preference change, but maybe there's people who had certain types of jobs and certain type of health conditions who were working before the pandemic and have now decided not to work after the pandemic. And that might be some part choice and some part constraint. 

Jennifer Dixon: Yes. I mean there seems, without getting all technical here, there seems to be two schools, don't there? There's the IFS work which is pointing to retirement and lifestyle choices leading to people age 50 to 64 dropping out early, and health possibly as a secondary reason. And then you have other economists like Haskell and Martin and indeed some of our own work at the foundation, which is suggesting the opposite, that health is the primary reason and retirement is a secondary, lifestyle is a secondary reason. Are you able to, in simple terms, just describe the differences between those two and why they're coming to different conclusions? 

James Banks: The easiest explanation of that is because right now the data we have are not very good. So one, you've got data, if you like, on the stock of inactive people and that shows a certain amount of ill health in that stock and a certain amount of lack of work. And you've got data on the flow who's leaving and who's joining, but of course you know need to have many, many observations of the flows to understand what's going on with the stock. And right now, as I said, I mean the real issue for me is that the real-time data we have on the workforce, if you like, is relatively crude in what it measures. 

Jennifer Dixon: Yeah. 

James Banks: It's only really, I think when we get the longitudinal studies, the things that follow people through their lives as they work, those kind of data sets have not been releasing their post-pandemic data yet, it's just not up to date enough. And so I think we always learn in economics, and well in all social statistics, you're really learning slowly about the trends that are driving, because you need that more granular information about mechanism. So I think at this time, it's rather too early to say definitively. 

Jennifer Dixon: Yeah. And just to press you a bit further, James, on anything more we know about this aged group that is retiring early, who are these people? Where are they working? 

James Banks: It's difficult to say really. I mean I've not looked myself at the way in which the jobs that the inactive people had, if you see what I mean, before they left. I mean again, it's going to be different between the people who are just leaving recently and the people who've left for a while. I would say again that if you look at the people who say they're inactive for health reasons, a lot of them have been out of work for quite a long time, even five years or more, certainly three or four years or more. And so one scenario is that actually it's the work itself or the lack of work that has been causing their health and their ability to work to deteriorate. We haven't spoken about the reverse, if you like, work can be good for your health and the lack of work can be bad for your health. You've really got to look at what they were doing in the past rather than just the jobs of the most recent retirees. 

Having said that, what we know typically about the way inactivity is patterned across the job and the income distribution is that we have this sort of inverse U shape. So we have the most inactivity both at the bottom of the skill distribution and at the top of the skill distribution. So you get wealthy early retirees post pandemic who have enough to live on, but they might not be the wealthiest in society, but they've just decided, ‘I just don't want to do the same kind of work anymore.’ And then at the bottom end you've got low skill, poor job, health constrains your ability to work. So you get that kind of inverse U-shape with most of the work going on in the middle of the skill distribution. 

Jennifer Dixon: Yeah, interesting. I don't know whether you saw it but I saw a recent survey for Public First and they commissioned a survey of 3000 adults over 50 pulled across Germany, UK and America and a booster of people who were not in the workforce and they compared the results and found that the UK stood out as people were significantly more likely to have negative attitudes to work and that the views had changed more profoundly since the pandemic than those other countries, which is quite interesting. So just turning to Sarah for a minute, just on that last survey, particularly of attitudes to work which I thought was quite interesting, it's only one survey, are you surprised at that kind of finding given all your work? And why might older workers not want to work? 

Sarah O’Connor: No, I'm not surprised by that finding at all. Yeah. So I spend quite a lot of time digging into what's going on in the world of work, sometimes through spreadsheets but often through getting out and about and talking to people and seeing what's happening in various companies. And I think it's clear both from the data and from the qualitative reporting that over the last few decades really what we've seen is an intensification of work. So people report that they're working harder, they're working faster, they're working to tighter deadlines. And then combined with that, and this is the bit that is kind of troubling from a health point of view, you're seeing a fall in the amount of autonomy that people have over their work. 

So far fewer people today, particularly lower paid people, say that they can make their own decisions about the way that they do things or indeed the pace at which they do things. And there's a huge kind of wealth of literature that shows that that is a very toxic combination for your health, working very hard, very fast to tight deadlines while also not having much control over the work. It's really the worst of all wells and can lead to all kinds of health issues. So the fact that we've seen those trends happening in the UK over the last couple of decades, I think, fits very well with the fact that we're also seeing rising levels of work-related stress and depression. 

So that was all happening before the pandemic and in many ways, I think the pandemic intensified that. Obviously, there were people who were furloughed, but for the people who continued to work, a lot of people found they were very stretched. People who were working from home found that the boundaries between work life and home life kind of completely dissolved. And while for some people, and I would include myself in this actually, quite enjoyed that flexibility, I have a young daughter and so it was quite useful for me, I think a lot of people really struggled with that. 

And then if you were an essential worker, you were working very hard to try and meet people's needs during this time while also taking on quite a lot of personal risk for your health which you were then worrying about for your family. So when you add all of that together, it kind of doesn't surprise me at all that basically a lot of people are feeling exhausted and stressed and burned out. 

Jennifer Dixon: And you've written about the rising tide of mental ill health at work and stress and I was looking at some of the figures on the NHS workforce which showed the particular significant uptick in stress and anxiety, particularly over the last couple of years. And I think you were mentioning the health and safety report that has just come out as well. 

Sarah O’Connor: Yeah. So the health and safety executive puts out annual statistics on work-related ill health. The biggest cause of ill health used to be musculoskeletal disease, that sort of thing, and then there were lots of industrial diseases that came from our past from mining and all the rest of it. But these days, fully half of all work-related ill health now is stress, anxiety, and depression. I mean it was rising before the pandemic but that's really accelerated over the last few years. I spent last week talking to employee assistance providers, so these are the kind of help lines that lots of decent employers pay to make sure that their employees have someone they can call if they're having personal problems, they're designed for mild cases of stress or depression, they might offer six sessions of counselling, something like that. 

They're meant to be more of a kind of preventative service, but what they were telling me was that they're just suddenly seeing this huge wave of people calling them with really much more serious and complex mental health problems up to and including people who are thinking of taking their own lives. And partly that's because I think people are struggling but it's also because it's very hard to get help in other ways right now. So GPs are hard to get appointments with obviously, there are very long waiting lists for mental health support, counselling through IAPT, and so you're seeing these employment assistance providers are suddenly picking up the slack. So I would say that that sort of thing is a warning sign for me that people are not doing well right now. 

Jennifer Dixon: And James, you've written a bit about, haven't you, mental health and the pandemic? There's a background picture, isn't there, that there has been an increase since the pandemic? So do we think that this particular uptick that Sarah is describing is pandemic related that will just abate or is it a longer run issue in the workforce possibly linked to some of the working practice changes that Sarah was describing? 

James Banks: I totally agree with everything that Sarah's just been laying out there. I mean there was a long run trend that was going on well before the pandemic. The rise of mental health as a leading cause of work disability or work ill health was happening well before. And particularly, that was what was driving disability rates in the young, for example, to sort of strikingly levels of the young who are either out of work on disability benefits or as Sarah was saying, in work with mental health problems. It's been a trend and I think one can link it to the changing nature of the labour market, not just the kind of stresses and strains and control and autonomy that Sarah was talking about, but more general issues, the movement towards the individual, the removal of collective bargaining, the lack of occupational health, the rise of solo self-employment, and the gig economy, all these things that are underlying those trends have been going on before the pandemic, and of course that made us more exposed in the pandemic. 

So the uptick that we saw that I wrote about in the pandemic was very, very severe. I mean we saw an acute rise in mental health problems during the pandemic and it was more patterns amongst women than men, although it was still striking for men, and part of was to do with combination of work and care for children that many women were dealing with in the pandemic. And again related to the types of jobs people were doing. 

And initially, that uptick, the mental health shock if you like, we found was most acute for younger women, although as the pandemic evolved, they were showing a bit more resilience and a bit more bounce back. And actually it was the late middle age and older women where we saw the more persistent negative mental health effects and they're both important in themselves and they are a risk factor for future physical health. We know that depression is a causal risk factor for cardiovascular disease and obesity and everything else. So, they have important long run consequences, and we will be seeing the effects of this for a long time. The one saving grace may be that at least we had a lot more talk amongst policy makers about the importance of mental health during the pandemic than we had done in the past because a lot of people have been talking about it for ages with little policy traction and certainly, I think there was more focus on it as a result of the pandemic uptick. 

Jennifer Dixon: Can I just go back to, just as a specific question about the young, particularly the men age 16-24. So there's been a particular increase here in the number, the share of that group that are economically inactive. So the figures I have here is 5% inactive in 2000 compared to 9% in 2021. Do we know anything specifically about that particular age group and particularly men? Is it mental health? Is it something else? 

James Banks: I haven't really looked into the causes for that age group. And then there is a big issue around skills and the conversion of skills from the education system into the labour market and that has particularly become more of an issue for low-skilled men. But how that would be classified, if you see what I mean, in activity, as I say a lot of these ONS sort of reasons for inactivity are self-reported, for low skilled men in particular. And this has happened as we've seen more of a bifurcation in the British education system. We don't have, like some continental European countries do, a sort of vocational track for skill development if you're not going to go to university. And increasingly that is coming down, I think, on low-skilled men who don't do particularly well at school. And then, so how they transition into the labour market and their opportunities, even in first job, let alone in career progression, I think that's pretty well documented, but I don't know how that translates into the specific rises in inactivity that we've seen most recently. 

Jennifer Dixon: Yeah. Sarah, I don't know if you have any insights in that particular group. 

Sarah O’Connor: Yeah, I looked into that a bit recently. So the rise in inactivity for young men, again when you drill into the self-reported reasons, it is often mental health that is ascribed as the cause. I think that's certainly the biggest increase for that group. But if you look back, it used to be that more young men were unemployed, and now there are fewer young men who are unemployed and more who are inactive and not looking for work at all. So I also wonder if there's something about the way the welfare system is or isn't working. 

Being unemployed these days and claiming job seekers' allowance or the universal credit equivalent is quite an intense process. You have a lot of requirements. You have to keep going to meetings, etc, etc. And I wonder whether that is driving some people out of the system altogether, which obviously is problematic because once someone is out of the system, and I think a lot of those young and active people are not claiming any kind of benefit, it's much harder for policy makers to then reach them in any meaningful sense. So I think that's part of what's happening as well, along with the other things that have been discussed around difficulty transferring from schools to the labour market. I mean we know that careers advice in schools in the UK is pretty dreadful and has been for a long time and there are not a hugely palatable group of options for young people leaving school if they didn't get decent grades. 

Jennifer Dixon: So people who are economically inactive, possibly for health reasons, they can still be claiming benefits, can't they? So even though it's very difficult and intense, as you say there, Sarah, to go through that process to get your benefits, do we know the proportion of economically inactive who are claiming benefits and is there something, I'm sorry to ask the Daily Telegraph question, is there something about the benefit system that might be incentivising people to become economically inactive? Or really, are benefits so punitively small that we can discount that as any incentive at all? 

James Banks: Well I think if... So it is true that the disability benefits, if you like, which are the ones that you can get on without having to be searching for a job, the rate of receipt of those amongst the young have risen compared to previous cohorts. So there's certainly something going on there. But as you say, the rates are really quite low. The majority of the British benefits system has gone to in-work benefits, which is precisely why the fact that Sarah was talking about the fact that there are people who are not in the work, just dropped out of benefit system really altogether. And so I don't think you could live on disability benefits, particularly if you hadn't made substantial contributions in the past for example. So- 

Sarah O’Connor: Yeah, I certainly don't think it would be a lifestyle choice. 

James Banks: No, exactly. 

Jennifer Dixon: No. 

James Banks: I mean compared to other countries; we don't have that kind of incentive to get on to disability benefits because the benefits are much less generous. And even then, there's a certain amount of reassessment and re-application. So I wouldn't say necessarily that's the mechanism that's driving this. 

Sarah O’Connor: I've actually, I've got the statistics if you want them? 

Jennifer Dixon: Oh, yes please. Yeah. Just do. 

Sarah O’Connor: So in 2019, which is the latest data I have 44% of workless young women were on benefits and 32% of workless young men. 

Jennifer Dixon: Right. 

Sarah O’Connor: So the majority are not on benefits. 

Jennifer Dixon: That's interesting. Thank you very much. So I just want to go back to the trends and the nature of work itself, which Sarah, you charted out very nicely. So you've also written about the sort of protective devices that can help protect workers that have become weaker over time. And I was reading about, you were saying that unionisation has halved and furthermore the governments haven't been enforcing labour legislation either. And you've also written about the health and safety apparatus, Health and Safety Executive, all of that has been weakened over time. So can you say a little bit more about the protective shield that has been in place to protect workers from, I don't know, health injuring or wellbeing injuring environments at work? 

Sarah O’Connor: Yeah, I think that's a good way to put it. So yeah, the UK is unusually bad at enforcing its own labour laws. I mean we have a pretty lightly regulated labour market anyway, but even within that we don't have very many labour market inspectors for the number of workers that we have. We've got a very fragmented system of looking after workers. There's the health and safety executive, looking at health and safety. If you're not being paid the minimum wage, then that's HMRC's problem. 

So it's all very piecemeal and there have been discussions about trying to bring all that together into a sort of single enforcement body that might do a better job. But the fundamental problem is that we just don't really resource this properly. You basically have a scenario where quite a lot of employers can act with impunity, and the perfect example of that would be the textile trade in Leicester, which I wrote about a few years ago, I mean an entire mini economy there where the going wage is about £4 an hour, even though the minimum wage has doubled that and that's out in the open, everyone knows it, every now and then when the media exposes it, the enforcement bodies go in and have a go at sorting it out. But actually they've never really got to grips with it. 

And even now, some of those problems persist. So yeah, there's an issue around the fact that the workplace protections that we're meant to have are maybe not particularly well enforced. And then, yeah, I mean in the UK, similar to countries all over the world, there's been a fall in the rate of trade union membership and so again, you've lost that route to protection and to trying to improve terms and conditions. 

Jennifer Dixon: Just for clarity, whose job is it to put all this together? This what I've called the protective shield, at least for health and safety and I guess wellbeing being part of that? 

Sarah O’Connor: Well there's a Director of Labour Market Enforcement, so I suppose you might say it's their job, but they really are just there to come up with a strategy every year and then hope that the various agencies follow through with it. But I wouldn't say that there's a good kind of holistic approach right now to this question. It's something that's been talked about a lot and I don't know if you remember, Theresa May ordered this review into the world of work and that was one of the recommendations that came out of it. But a lot of those recommendations, they were decent enough, but they've fallen by the wayside in all of the political chaos that has ensued. 

James Banks: If I could just come in there, I mean we've had, I think that Taylor review, it wasn't the first either. I mean I was on the expert panel for Carol Black and David Frost's review of sickness absence at work 10 years previously in sort of 2010. And we were talking about the decline in occupational health and the important role of good jobs for health, and in particular to prevent the onset of ill health at work that would then lead to early retirements. So I think we have had a number of reviews where these things have come up. 

But like Sarah says, it sort of falls a little bit between the cracks and particularly when you get away from the workplace protections in manufacturing sector where there are obvious health and safety risks, but when you get to more wellbeing protection and most of employees are not in the manufacturing sector, they're in service sector or they're self-employed where it's much harder to identify a health and safety risk. But this issue of worker wellbeing is much more of a generic occupational health issue. And I think that's really where it's very difficult to know whose baby this is, as it were. 

Jennifer Dixon: Yes, I mean work can be safe in terms of being injured, but as Sarah was saying earlier, the kind of nature of the work and the intensification and the lack of autonomy and the pressure put on staff, I mean that's the kind of management practice and that must be very difficult to move into, particularly for a government of this stripe. Just think about Twitter. 

James Banks: No, absolutely. And in general we've had a movement towards the individual and away from whether it's unions, employers, or the welfare state really. So lots of things employers provided used, even from things like defined benefit pensions, we've moved away from that. But that various things around esteem, security, and it's that linked with the lack of collective bargaining or reduction in that that I think we have got a much more individual-based system and it's not clear where all these supports do come. And again, I would go back to occupational health because NHS itself used to have quite a strong occupational health arm, which was sort of dismantled. 

Jennifer Dixon: Yes, indeed. I mean you would think, wouldn't you, that now after the pandemic and the fact we've got a labour shortage and we've got low levels of unemployment, that now would be the time to devote a lot more attention to the health capital of the working age population to put it in those terms? The red lights couldn't be flashing more brightly, we have had government talking a little bit about this, some ministers recently, but are we seeing much action whether it's coming from government, unions, or businesses? 

Sarah O’Connor: I think we have, but it's often the sort of bigger, more prosperous, more white-collar employers that do more of this kind of thing. I mean we have seen an awful lot, obviously, of wellbeing initiatives. I mean there's an open question about how effective some of them are and certainly I've spoken to plenty of workers in places like big accountancy firms or whatever where they feel quite frustrated that they're being offered meditation sessions at lunchtime, but their real problem is that they're massively overworked and understaffed. So you've got to take some of that with a pinch of salt. But I think certainly, at least rhetorically, I think companies are taking it more seriously. 

I mean I think for me the more interesting thing is the changing balance of power in the labour market, and you alluded to the fact that unemployment is very low and there are labour shortages right now, partly of course because of this phenomenon that we're talking about, a fair number of people have left the workforce. And I do think that you've started to see over the last year or two that begin to play out in terms of employers realising that they need to do better in order to get people to come and work for them or to stay with them. 

I've noticed it in things like employers of lower paid staff offering maybe more flexible shifts, even seeing things like abattoirs offering shifts that people can manage around the school run and that sort of thing. You would not have seen that a few years ago. They would've just said, ‘It's a 12-hour shift. Take it or leave it.’ So I think there has been a sign simply because workers are hard to find that employers are trying to do better by them. My concern though is that we're now heading into a recession, unemployment is forecast to rise, employers are beginning to cut costs and worry about how they're going to get through the next few years. So I wonder whether that will prove to be quite a short-lived phenomenon. 

Jennifer Dixon: I noticed the CBI, at their conference, they have launched something called the Health Index, which is a way of having big industries try to measure the health in a systematic way to be able to compare over time and with each other what the health of their population, not just occupational health but wider wellbeing metrics, which is quite interesting that it's coming from the CBI. 

James Banks: So that initiative actually is part of a broader initiative, which I've been a little bit involved in, a group called Business for Health. 

Jennifer Dixon: Yes. 

James Banks: And that actually, it was quite interesting because that was an offshoot of the previous all-parliamentary group on healthy life expectancy. It was sort of meeting to discuss what could be done to address these goals in healthy life expectancy that have been out there for a few years. 

One of the things that that group was talking about was that there was no discussion of the role of business in the healthy life expectancy agenda and the Business for Health Group actually, it was a rather large of employers that had got involved thinking precisely about what, in terms of businesses as employers, businesses as producers of goods and services, business of consumers, so there's many roles in which business interfaces with the factors that are driving people's health and this index is just really, I think, the first output of that kind of group. 

So I think it is a really interesting direction of travel and I agree with Sarah that as the recession begins to bite and things begin to tighten, it'll be interesting to see how these things play out. But I would also note that there's quite a lot of businesses now talking about the fact that they've moved to four-day weeks without a loss of productivity. So I think that this idea that good jobs can be both efficient as well as good for people's health is beginning to a little bit of traction there. 

Jennifer Dixon: We've had a podcast previously on the role of investors and how they are trying to begin to weave in health into their, what's called ESG practices. So doing health audits as well as carbon audits for example, in requiring the businesses they invest into. Now that's early days, but at least it's an effort, isn't it? 

James Banks: Absolutely. And there's a good analogy there, because 15 years ago people in the ESG investing world were saying, ‘Well, if you're going to have ESG principles, you're going to be having to compromise the rate of return that you're going to get.’ As of one or two years ago, people are saying, ‘Actually, you don't lose any returns for ESG because that's where the returns are.’ If you see what I mean, so I think it's becoming much easier for funds to have environmental constraints because I think that's where the returns in the asset markets are greatest, precisely because of the way the world is going. And so it may well be the same thing with work, at some point there might initially be a price, but after some point in time, they might be because of the way the nature of markets, as Sarah is talking about, it may well be that you don't have to compromise too much on efficiency to have these kinds of goals. 

Jennifer Dixon: So we've talked about businesses and investors, we've talked a little bit about government and the sort of fragmented and not pull together sort of strategy here to improve and help workers at work. Sarah, what about the unions? I mean halved as they have been, but are they showing much active? 

Sarah O’Connor: I think they are interested in this area. The problem for the unions is that the sectors where these problems are often most acute are the ones that are very hard for unions to get a foothold in. So, gig economy platforms, for example, even Amazon warehouses, unions have tried and failed for years now to unionise. A lot of these sectors where people are working quite individually, where the staff turnover is quite high. It's tricky, it's tricky for unions, but I mean they are trying and we have definitely seen some signs of improvement. 

From a union's point of view, I think they feel fairly optimistic at the minute. I think they are seeing that they are getting more members in some of those areas. We've had some interesting things like the GMB has kind of formed an agreement with Hermes and also with Deliveroo to try and improve working conditions, and that would include things like health and safety focus. So you are starting to see unions make some headway, but it's a big task and it's fundamentally just quite difficult in these sorts of areas. 

Jennifer Dixon: Yeah. And this environment as well. Great, thank you. So maybe just to finish, I'll put you both on the spot. Times are tough at the moment, obviously we've got huge challenges and a rising tide of ill health and the economically inactive. What are the types of things that you think would you like to see happen in the short term? Where might be some hope and some progress that we could make? Or does the government, for example, just need to wait because with the economically inactive, the cost of living may just force people to reconsider and come back to the workforce, so we might have a great join up rather than a great quit? 

James Banks: The second part of your point, the just waiting for people to go back to work because times get hard isn't going to help with the health issue. So it might help with the work issue, but the jobs that are bad for people's health are going to have long-run consequences regardless. So I think that we must remember that it's a joint work and health agenda, not just a work agenda. 

Regarding what to do, I mean I think the short term is hard. I would come back to what we've been talking about, about mental health services, mental health support at work, occupational health as the things that one could turn on the tap quickly. I think issues around the trends in the nature of work are very, very difficult to think about. And in the longer term, one has to think we would certainly be in a better place if we had, for want of a better word, the good jobs agenda had more traction. But I think one has to look also to lifelong skills and I think that that is a long-term agenda because you're really building a platform of good jobs and career profession and skills for the younger cohorts and that can take a generation to realise, and generational changes are very difficult for governments. Short-term policy and very difficult to commit to things that look expensive now that aren't going to have payoff for many years. So it's a very, very hard problem, I think, for the long term. 

Jennifer Dixon: Yeah, although we do have the green agenda to point to, don't we, with the net zero target and that spans a generation, doesn't it? So it's sort of viewing health as a capital as well as green capital that some have talked about. Thank you. So, Sarah? 

Sarah O’Connor: Well there are some things you could do in the short term that would be helpful. If you're thinking about people who've left the labour market, whether because of ill health or because they've retired early, we know that quite a lot of those people say they would like to go back to work if they could. A lot of them are outside of the benefit system, so there's not really anywhere they can go right now for help. So having some kind of public employment service that's open to absolutely everyone, I think, would be one thing we could do. So people could go in and get help with their CVs, think about careers, find out what jobs are on offer. That's the sort of thing that if you're not on an unemployment benefit, it's not easy to get that kind of help. So that's something in the short term. 

In the longer term, I would raise taxes a lot and spend the money on trying to fix the nation's health because I think until we do that, we're trying to grow the economy while limping along with a population that is really not very well. And I just don't think that that's going to work. So I think we just need much better provision of health care, community health care, preventative health care, public health, mental health support, and then we need to think about how to improve the nature of jobs, particularly for people on lower pay so that jobs themselves aren't part of the problem, but instead are part of the solution. 

Jennifer Dixon: That's a great place to end. Thank you both very, very much. That was a really rich discussion. Now, we've referred to a lot of relevant analysis in this podcast, including pieces from James and Sarah themselves, as well as Institute for Fiscal Studies, the Health Foundation, Haskell and Martin, and so on. All of these are in the show notes so do take a look. Next month we'll be taking a festive look back at the year, drawing on some wonderful insights from this year's series of 11 podcasts. Until then, it's goodbye from me, Jennifer Dixon, and as ever, big thanks to colleagues Kate Addison and Grace Everest at the Health Foundation and the production team at Malt. 

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