Gareth Millward's Sick Note: A History of the British Welfare State is the result of a Wellcome Trust Humanities Fellowship and represents detailed archival research on the history of the sick note, or doctor's medical certificate, in the British welfare state. The sick note provides the bureaucratic gateway to social security sickness payments and employers’ sick pay. Millward argues that it also carries powerful cultural meanings, legitimizing people's claims to being sufficiently ill to be absent from paid work or to be entitled to payments from the state. Despite this legitimizing status, the sick note also carries connotations of “malingering” (32) or cheating. Millward explores how policy makers, doctors’ organizations, employers, and the media have viewed the sick note as a cultural symbol of both legitimacy and deceit from 1948 to the present day.
Millward shows that sickness and eligibility for sickness payments, whether through the state or employers’ sick pay, is deeply embedded in social structures. Sickness prevalence is affected by the type of work that people do and eligibility for payments is affected by the ways in which capacity for work is assessed. In turn, each of these is affected by social structures of gender, age, social class, disability, and ethnicity, as well as changing medical and cultural expectations over time. Millward has a close focus on the bureaucratic and cultural meanings of the sickness certificate, both within social security systems and within the workplace. Millward begins Sick Note in 1948 at the foundation of the National Health Service and new National Insurance and means-tested social security schemes within a culture of postwar national renewal. From there, Millward provides detailed analysis of the changing expectations of the role of the family doctor (general practitioner) in certifying illness during periods of significant social change, economic crises, and the recent challenges of the COVID-19 pandemic.
Chapter 2, “The ‘Birth’ of the Sick Note,” begins in 1948, providing detailed analysis of contemporary debates in medical journals, newspapers, and Parliament, showing the concerns of doctors, politicians, and others about malingering and about the potential burden on general practitioners in the newly launched National Health Service.
In chapter 3, Millward turns to absenteeism in the workplace, looking at four postwar public sector industries, chosen for their importance in the nation's imagined postwar rebuilding: the Royal Ordnance Factories, the National Coal Board, the Metropolitan Police, and the Post Office. He shows that similar debates were conducted across these diverse industries: the perceived problem of malingering, the validity of the sick note, and the intersection between sickness absence, manual labor, industrial injuries, class, gender, age, and other structural issues within the workforce. In an interesting contrast to the discourse on malingering, he quotes a medical officer of the Post Office who recognized that an employee's fitness for work was also affected by how happy they were in their workplace and the structural issues that affect this (67). A reference to the “industrial chaos” among cats employed by the Post Office as mousers provides some humor among all the detail (70).
In chapter 4, Millward addresses the sick note as a symbol of a male breadwinner model of the welfare state. He uses archival material related to National Assistance (the postwar means-tested social security benefit). By using National Assistance records Millward is able to analyze the effect of the sick note on workers and benefit claimants who did not meet the standard male breadwinner model, for example, women, newly arrived migrant workers, and workers in insecure and low-paid work. Here he finds racist and gendered bureaucratic procedures that added extra layers of control to people's claims for benefits.
In chapter 5, Millward focuses on the privatization of the sickness benefits system in Britain with the introduction of statutory sick pay, which moved responsibility for short-term sick pay from the state to the employer. The role of the general practitioner as the gateway to sick pay continued to be hotly contested by doctors, who objected to being expected to make recommendations about whether a worker really was sick.
Chapters 6 and 7 move chronologically through various crises of the welfare state into the twenty-first century. Panics about rising numbers of benefit claimants led to changes in benefit rules and attempts to remove the general practitioner as the main assessor of capacity for work. The early twenty-first century sees “the death of the sick note” (chapter 7) when it was renamed as a “fit note” (180). Evidence suggests that renaming it has changed little in the culture of medical certificates.
These chapters include explorations of popular cultural understandings of the sick note, through the use of archive newspaper data and archived online sources. These sections do not sit very easily with the mainly chronological approach, sometimes interrupting the narrative flow of policy development. However, they provide fascinating insights into how the sick note is discussed away from the bureaucracy of the welfare state.
In the final chapter, Millward considers how the COVID-19 pandemic interrupted expectations of work and sickness during a major public health crisis. There was a change from the culture of presenteeism to discouraging people from going to work to reduce infection. Pressures on the National Health Service meant that requirements for sickness certification were reduced. The pandemic highlighted inequalities: those in frontline work or insecure employment were less able to claim sickness payments, a situation that, again, underlines the importance of wider social structures.
Millward provides a meticulous historical analysis of the role of the sick note. The level of detail is impressive, and Millward provides illuminating insights into the relationship between policy makers, bureaucrats, doctors, employers, and the media in the history of the sick note. With its focus on the British welfare state, Sick Note provides a wealth of material for British historians and social policy analysts. It is also relevant to readers concerned with the legal and cultural significance of sickness certification in any national context.
