Fifty years ago: Assessment of the ability to work of the ‘Unfit’

In the Apothecaries’ Lecture given before this Society on 25 March last year, Doctor Lloyd Davies said: ‘For every spell of sickness for which benefit is paid due to prescribed industrial diseases, there are three hundred spells from nonindustrial disease. The patient’s general practitioner is responsible for determining fitness for work after an illness. No one would challenge this. Equally the majority of patients return to work successfully. There remains, however, a burden of distress where selected patients would be helped by skilled advice, not about their illness, but about how their work is affected by their illness. How big this burden is I do not know but I suspect it is very considerable.’ I wish to discuss the question of return to work and responsibility for determining fitness for work after illness. At first glance it may be thought that there is no problem at all. As far as industry is concerned it is becoming more complex and the worker’s tasks are becoming more selective and skilled. The worker is either able or unable to do his task. As far as the general practitioner is concerned the patient is either fit or unfit. This all seems quite straightforward and simple, so why should we challenge it? Do any of us believe that a man becomes fit overnight from a long and debilitating illness? At what stage during the patient’s recovery should the general practitioner reach for his pen and sign the final certificate? What is fitness anyhow? A man may be unfit to be an airline pilot but this does not mean that he is unfit to do any work. Often it must be very difficult for the general practitioner to decide just when his patient may return to work and if he has little or no knowledge of the patient’s work then the decision is an arbitrary one. In industry, it is much easier to have people coming back to work fully fit for their tasks. Everything is arranged for people to do certain tasks. Any adjustment or alteration of this is inconvenient and is often thought to be uneconomical. We reach a stage where a manager will say ‘I don’t want that man in through the factory gates until he is 100 per cent fit.’ The social security system contributes to this problem. The worker is either fully fit for his full-time employment or is totally unfit and needs social security benefits. It seems that work is held to be a necessary evil and that we work only in order to eat. If we believe this is true then there is little wrong with the present system, but Garland reminded us in his paper on ‘Fraser’s Disease’ that work provides many areas of satisfaction in our lives. I wish to base my argument on the premise that to want to work is normal. I want to show how one industry has evolved a system of providing a gradual return to work after illness, to show that this is a useful and perfectly practical measure and to argue that this is one of the most useful spheres of work for the industrial physician.

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