James Latimer is a GP and Occupational Health Physician practising in the North East of England
It was a Wednesday morning – the sort that arrives grey and uninvited when I first met Mr H.* He had been asked to see his GP about his back pain by his employer, a logistics company based on the outskirts of a town that had once thrived on steel and coal and now thrived on very little at all. Mr H was fifty-three and he had worked for the same company for twenty-six years. So engrained was his work that he arrived in a fleece that carried the company’s logo on the chest — still wearing the uniform of a job that had taken so much from him.
And yet, somehow, work — the thing that most adults spend the majority of their waking hours doing — often gets treated as an afterthought. A background detail.
“I’ve never had a day off sick in my life,” he told me. “Not until last year.”
An MRI had confirmed a prolapsed disc at L4/5, but as I sat and listened, it became apparent that the back pain was only one part of a much larger story. His wife had left. His eldest son had moved south for work. He lived alone now, in a house that had once been full, and he came to work not because of the money, though the money mattered, but because work was the last remaining structure in his day. The last thing that told him what time to get up in the morning.
“When I’m off sick,” he said, staring at his hands, “I don’t know what to do with myself.”
In medicine, we talk a great deal in medicine about the social determinants of health — housing, diet, income, education. These are the upstream factors that shape a life long before the patient ever reaches our consulting room. And yet, somehow, work — the thing that most adults spend the majority of their waking hours doing — often gets treated as an afterthought. A background detail. Something to record on the clerking form between marital status and next of kin.
The evidence is unambiguous, even if our clinical practice hasn’t always caught up with it. Being in good work is better for your health than being out of work.¹ Not marginally better. Substantially better. Unemployment is independently associated with increased rates of cardiovascular disease, poor mental health, limiting long-term illness, and — at its most extreme — suicide.¹ The relationship runs in both directions, of course. Poor health causes unemployment. Unemployment causes poor health. A cycle that, once established, can be extraordinarily difficult to break.
In 2024/25, the Health and Safety Executive estimated that 40.1 million working days were lost in Great Britain due to work-related ill health and non-fatal workplace injuries.² Stress, depression and anxiety alone accounted for 22.1 million of those days — each person suffering taking an average of 22.9 days off work.² To put that into some context: if you stacked those lost days end to end, you would not reach the end of them for over 110,000 years. And yet, for all the enormity of those numbers, I wonder how often we ask our patients — really ask them — about their work.
There is a concept in occupational medicine that I find myself returning to again and again. Waddell and Burton, in their landmark 2006 evidence review, concluded that “…work is generally good for physical and mental health and wellbeing.”³ They were careful to qualify this — not all work is equal, and bad work can be as harmful as no work at all — but the central thesis has held firm in the two decades since. Work, when it is good work, provides something that medicine struggles to prescribe. It provides structure. Purpose. Social connection. Identity. Income. The things that, when stripped away, leave a person adrift.
But what if the work situation is the presenting complaint?
I think about this often when I am sitting across from a patient who is on their fourth sick note in as many months. The temptation, and I say this as someone who has been guilty of it, is to treat the presenting complaint and leave the employment situation well alone. The back pain gets the referral to physiotherapy. The anxiety gets the sertraline. The work situation gets a polite note on the fit note that the patient is “not fit for work” and will be reviewed in four weeks.
But what if the work situation is the presenting complaint?
What if the back pain is being maintained, not fabricated, but genuinely maintained by a job that involves eight hours of manual handling with no ergonomic assessment and a line manager who responds to absence with suspicion rather than support? What if the anxiety is being driven by a zero-hours contract, the uncertainty of which means that the patient cannot plan their finances, their childcare, or indeed their life, beyond the next fortnight?
Not all work is equal, and bad work can be as harmful as no work at all. These are occupational health questions. But they are also, inescapably, primary care questions.
The fit note, which is increasingly being discussed in many circles, was introduced in 2010 to replace the old “sick note” and was designed, in part, to shift the conversation from what a patient cannot do to what they can do.⁴ In theory, it was a step towards recognising that work and health are not opposites but partners. In practice, it is often completed in the final two minutes of a ten-minute consultation, by a GP who has neither the time nor the occupational context to make a genuinely informed judgement about what a patient’s workplace is actually like.
This is not a criticism of GPs. It is a criticism of a system that asks GPs to make occupational recommendations without the occupational information to make them well. I have lost count of the number of fit notes I have seen that recommend “light duties” for a patient who works in a call centre or “reduced hours” for someone who is self-employed and whose income disappears the moment they stop working. These are not bad recommendations made by bad doctors. They are reasonable recommendations made by good doctors who have been asked to operate in a vacuum.
The gap between general practice and occupational health in this country is, frankly, too wide. Only around 15% of UK workers have access to occupational health services through their employer.⁵ The rest, the self-employed, the small business employees, the gig economy workers, the zero-hours contract holders, arrive in our consulting rooms with work-related problems and leave with healthcare solutions that may or may not address the root cause.
Back to Mr H.
By the end of our consultation, I had a clearer picture. The disc prolapse was real, but it had been aggravated by the nature of his work — repetitive heavy lifting without adequate equipment or training. His absences had escalated not because he was malingering but because each time he returned to work, nothing had changed. The same lifting. The same hours.
I wrote a report. I recommended a phased return with modified duties, a formal ergonomic assessment of his workstation, and a referral to the Employee Assistance Programme for some psychological support. Three months later, Mr H was back at work full time. He sent a card to me. It said, simply: “I feel like myself again.”
There is a broader point here that goes beyond any individual consultation. We are living through a period of significant change in the nature of work itself. The pandemic accelerated a shift towards remote working that has brought genuine benefits for some and profound isolation for others. The gig economy has created a generation of workers with flexibility but without security. Economic inactivity due to long-term sickness has risen sharply since 2020, with the North East of England consistently recording some of the highest rates in the country.⁶
What if the back pain is being maintained, not fabricated, but genuinely maintained by a job that involves eight hours of manual handling with no ergonomic assessment and a line manager who responds to absence with suspicion rather than support?
These are not abstract statistics – rather they are the people sitting in our waiting rooms. They are the fifty-three-year-old logistics worker in a company fleece. They are the thirty-one-year-old delivery driver whose lower back has given way after three years of twelve-hour shifts. They are the forty-five-year-old teacher who has been signed off with stress and is terrified that if she doesn’t go back soon, she never will. They are the patients asking us, sometimes explicitly, more often implicitly, not just to treat their symptoms but to understand the world in which those symptoms have arisen.
Bernardino Ramazzini, the seventeenth-century Italian physician widely regarded as the father of the Occupational Medicine in his 1700 treatise De Morbis Artificum Diatriba (Diseases of Workers), argued that no physician could properly understand a patient’s illness without first asking about their occupation.⁷ He suggested adding a simple question to the traditional clinical enquiry: “What is your trade?”
Three hundred and twenty-five years later, we are still not asking it often enough. Not “What do you do?” in the passing, polite sense. But genuinely: What is your work like? Is it safe? Is it secure? Does it exhaust you? Does it give you purpose? Does it treat you with dignity? The answers to those questions, the ones that rarely make it into the consultation, may tell us more about a patient’s health than any blood test we order.
Mr H reinforced that work is not merely an economic transaction. It is not simply the exchange of labour for money. For many people, perhaps most people, it is the architecture of their daily life. It is the reason to get up. The place where they are known. The source of their self-worth. When that architecture collapses, something more than income is lost. When we as clinicians, fail to ask about it, fail to understand it, fail to advocate within it we are missing something fundamental about the person sitting before us.
The fit note may say “not fit for work.” But sometimes, what the patient is really telling us is something far more complicated than that. Sometimes they are telling us that work — good work, fair work, work that sees them as a human being rather than a resource — is the very thing that might make them well.
*Author’s note: The fictionalised patient in this narrative is based on an accumulation of clinical experiences during the author’s occupational health practice and does not represent any specific individual, living or deceased.
References
- Public Health England. (2019). Health matters: health and work. GOV.UK. Available at: https://www.gov.uk/government/publications/health-matters-health-and-work/health-matters-health-and-work
- Health and Safety Executive. (2025). Working days lost in Great Britain, 2024/25. HSE. Available at: https://www.hse.gov.uk/statistics/dayslost.htm
- Waddell, G. & Burton, A.K. (2006). Is work good for your health and well-being?The Stationery Office, London. Available at: https://www.gov.uk/government/publications/is-work-good-for-your-health-and-well-being
- Department for Work and Pensions. (2010). The fit note: guidance for patients and employers. GOV.UK. Available at: https://www.gov.uk/government/publications/the-fit-note-a-guide-for-patients-and-employees
- Black, C. & Frost, D. (2011). Health at work – an independent review of sickness absence. The Stationery Office, London. Available at: https://www.gov.uk/government/publications/review-of-the-sickness-absence-system-in-great-britain
- Office for National Statistics. (2024). Economic inactivity by reason and region, UK. ONS. Available at: https://www.ons.gov.uk/employmentandlabourmarket/peoplenotinwork/economicinactivity
- Ramazzini, B. (1700/1940). De Morbis Artificum Diatriba(Diseases of Workers). Trans. W.C. Wright. University of Chicago Press.
Featured photo by Markus Spiske on Unsplash
