The economic costs of ill-health, and the role work can play in supporting good health, have moved back to the top of the policy agenda since the Covid-19 pandemic.

Nearly three million people remain economically inactive due to long-term sickness, while the Government’s Keep Britain Working agenda has placed renewed focus on the role employers, healthcare providers and public services can play in helping more people stay in and return to work.

That renewed focus is welcome but it is not a new diagnosis. In 2008, Professor Dame Carol Black was asked to review the health of Britain’s working-age population and set out recommendations for reform. Nearly two decades later, as the UK prepares for another change in Prime Minister, there have been eight occupants of No. 10 since that review was published.

Speaking to Ben Harrison (Director, Work Foundation at Lancaster University) at the Work and Health Summit, Dame Carol reflected on why successive Governments have struggled to turn evidence into lasting reform. Here are five key takeaways from the conversation.

1. The diagnosis has been clear for years, but delivery has fallen short

Dame Carol was frank that many of the problems identified in her 2008 review remain unresolved. “The problems that I and other people highlighted from 2008 are still with us,” she said. “The structural problems have not gone away.”

She argued that the UK still needs to do far more to prevent ill health and provide earlier support when people develop health conditions. While some Scandinavian countries faced similar challenges in 2008, Dame Carol said they had made greater progress by creating stronger incentives for individuals and employers to support people back into sustainable work. The UK, by contrast, has not moved far or fast enough.

While she welcomed the progress many employers have made in taking health and wellbeing more seriously, Dame Carol argued the UK still lacks a joined-up strategy that brings Government, employers and individuals together around a shared goal.

She said there had been a failure to build a robust system capable of surviving political change and translating evidence into practice. “We have fiddled at the edges,” she said. “We have wonderful initiatives. We have so many of them. We have so many fragmented bits.”

2. Good work must remain at the heart of reform

The quality of work matters. There are now 6.8 million people in severely insecure work lacking the rights and protections that many of us take for granted. Dame Carol stated clearly that good work supports health, wellbeing and labour market participation.

“If you want people to be in work, it needs to be good work”, she said.

That matters as Government seeks to reduce economic inactivity and support more people with long-term conditions into employment. A narrow focus on moving people off benefits and into any job risks missing the point. Work can be protective, but only if it is secure, supportive and designed around what people can do. The new Employment Rights Act has the potential to raise minimum standards and support health.

As Dame Carol put it: “I wrote in 2008, believe that good work is good for you. I believe that people have assets and you should look at what people can do, not what they can’t do.”

3. Early support is critical and waiting until crisis point is too late

One of Dame Carol’s strongest messages was the need to intervene much earlier when someone begins to struggle with their health at work.

“You don’t wait until somebody’s been out of work for sort of, I don’t know, three months before you start to talk to them,” she said. “After six weeks, you’re on a downward spiral. And that spiral just continues.”

This has major implications for employers, GPs, occupational health providers and JobCentres. Too often, the system only engages someone once they have already fallen out of work or entered the benefits system. By that point, the route back can be longer, more difficult and more expensive for individuals and the state.

Dame Carol argued for a system that helps people stay connected to work, with employers and workers having honest conversations early, supported by the right expertise where needed. It also means improving the fit note so it focuses on what someone can do, rather than simply certifying what they cannot.

4. Support must start with the realities of people’s lives

The reasons someone struggles to attend or remain in work are often complex, and Dame Carol warned against viewing health and work through a narrow medical lens.

“You shouldn’t just be trying to solve health problems,” she said. “Often what underlies a health problem are things like domestic violence, all kinds of things which you need a way of getting at.”

Her preferred starting point is not to ask: “What’s wrong with you?” Instead, she said: “I would say, what is it that keeps you from work? What are the problems?”

That question could reveal a very different set of needs: a musculoskeletal condition that could be managed with the right chair, caring responsibilities, financial insecurity, stress, or an unsafe home environment. The policy implication is clear that support must be holistic, personalised and fast enough to prevent problems escalating.

5. Reform must be evidence-led, honest and built to last

Dame Carol ended on a note of cautious optimism, pointing to the energy she has seen locally and the appetite among employers and public services to do things differently.

But she argued that real reform will require political courage and patience. The next phase cannot be another short-lived programme or pilot that disappears before it has had time to work.

She called for “a very strong Secretary of State in the Department for Work and Pensions” with “the courage and the vision and also the resilience and the patience” to drive long-term reform. She also called for more honesty about what works.

“What’s wrong with failing?” she asked. “Start again or readjust.”

That may be the most important lesson 18 years on. The UK does not need to rediscover the link between work and health. It needs to act on it with consistency, accountability and urgency.

As Dame Carol put it: “We all want more people in work healthy and well.” The task now is to build a system that can make that ambition real.

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