Professor Sir Mansel Aylward CB, chair of Public Health Wales, tells Sarah Bennett and Richard Purcell how self-esteem affects health and why happiness is a constant
Professor Sir Mansel Aylward is chair of Public Health Wales, a unified NHS Trust responsible for the delivery of public health services at national, local and community level in Wales. As director of the Centre for Psychosocial and Disability Research at Cardiff University he is also continuing his renowned research into the obstacles to returning people to work after illness.
How did your career develop from medical practitioner to public health expert and professor?
My background is in rheumatism and because of my interest in pain I became interested in the placebo effect, psychological medicine and the power of belief. That eventually brought me into public health. In terms of my research career, I have focused on longevity, working life, disability-free years, resilience, attitudes to returning to work after a period of absence and the impact of socioeconomic differences.
What would you describe as a highlight of your career?
First, the work I led to ensure people with a terminal illness received their state disability benefit quickly. Second, introducing the 'All Work' test in the 1990s, which was an objective approach to measure whether someone could do their own work or any other work. People expect me to say that my career highlight was being knighted by the Queen, but the Queen knighted me because of this work.
What do you think are the main factors affecting health and well-being?
It is worth defining what we now mean by 'healthy'. It is no longer whether or not you are suffering from a particular illness, but if you are able to adapt and cope when faced with physical and emotional challenges.
There is a strong correlation between health and how much control people have over their life. Certainly we have to try to stop smoking, drink less and improve our diet in order to be healthier. But for poorer sections of society their circumstances mean they have less control over their life and are more likely to have lower self-esteem, which is a major problem. We should be looking at the social determinants of ill health. Epigenetic effects brought about by the environment and behaviours of the mother are important determinants in the development of children. This means that individuals' circumstances are often inherited. Education is key to helping families and children to change and improve their circumstances.
The Cardiff Health Experiences Survey suggests that psychosocial factors are most significant in preventing people from returning to work. Are these variables consistent throughout life and, if so, could they predict long-term disability?
Research shows that we all have a 'set point'. We maintain the same levels of happiness throughout our lifetime. A traumatic experience will depress our levels of happiness for a short period and then they will bounce back to their long-term set point. We have developed a tool to measure a person's psychosocial score (negative influences on returning to work), which could be as powerful as a genetic test and could accurately predict disability in 80% of cases. But if it is as powerful as we think, it should be excluded as a rating factor in the same way as genetic testing. We do not want it used to prevent people from being insured.
So is it fair to charge the same premium for people with different set points?
Yes. That is what insurance is for, to pool risk.
In January the UK government gave its response to Health at Work - an Independent Review of Sickness Absence, published in November 2011. Did you find the response encouraging?
The government response was not as well thought through as it could have been in several areas, first in relation to the health and work assessment and advisory service. When I was medical director of the Department for Work and Pensions we introduced the all work test, and made a lot of assumptions about the number of medical professionals needed to support it. With hindsight, we needed two or three times more.
The second issue is that people will be picked up who are off for four weeks or more, and if the GP has not dealt with it, the patient will be referred. We know that GPs are not comfortable with fit for work assessments; only 40% are happy to conduct them. About 5% have been assumed to refer cases. What if 50% refer?
Third, I am concerned that all the benefit of educating GPs will be lost, which will be an obstacle to achieving the outcome we want. It is important for the GP to manage the patient through the system and it worries me that this responsibility is being taken away.
Fourth, case management is a critical skill we need to recognise as it creates a pathway back to work. The continuity and motivation it provides builds confidence and means people will return to work more quickly. We have seen in some cases that increased confidence can even offset a further deterioration in health.
There has been negative publicity on 'activities of daily living' definitions of disability because the objective tests have been strictly applied. What are your views on functional assessment tests (FATs) as a measure of disability?
I do not support formalised, machine-driven functional capacity tests. I support functional assessments as elaborated in the all work test, personal capability assessment and as now modified in the work capability assessment. The all work test that we designed in the 1990s lasts 45 minutes and the results need to be interpreted along with other medical evidence. The assessment must be impartial and independent and the focus should be on the individual's ability to return to work. 'Activities of daily living' definitions are not the same as a functional assessment of body and mind. Any test of this nature is not completely objective.
What are your views on the new Universal Credit state benefit system?
The Universal Credit system is a good development as I think it encourages people to return to work. I am a supporter of means-tested benefits and so I have no problem with the concept, but we need to look at the detail and the unintended consequences. For example, while means testing and conditionality makes sense for a single person, we need to look at the impact beyond that for dependants.
Clearly where people are able to work then they should not be receiving benefits. On the other hand, if you start reducing the level of benefits for households on the edge of poverty you run the risk of moving people onto a trajectory downwards, resulting in mental health issues and other health problems.
Does the inevitable trend to reduce state benefits create an opportunity for insurance companies?
Changes to state benefits do not necessarily have an impact on insurance. This is because these people do not think about or are not able to buy insurance anyway. Perhaps there is an opportunity to extend Group Income Protection cover to blue-collar workers, but this is expensive for employers.
What are the challenges for insurers?
People predict the future based on false beliefs - having children, getting married or winning the lottery doesn't necessarily make us happy. Research shows we are more optimistic than realistic and believe that 'it won't happen to me'.
How do you find working with actuaries?
Very difficult. In my experience actuaries are very conservative and resistant to change. We can't do without actuaries and I value what actuaries do, but they have a poor image.
I would like to second some actuaries into the unit and work more closely with them. When I speak at an actuarial conference I am asked questions that I can't answer. It would be useful to have an actuary's perspective.
What advice can you give to actuaries working in health and care?
Actuaries need a better understanding of health and care and a better grasp of the impact of demographic changes. For example, the impact of ageing may not be as great a burden on society as it first appears. People are more health conscious than ever before, and older people play an active role in society.
What are your views on working in old age? Does your mantra "work is good for you" apply above age 65?
I believe that working in old age is a good thing but it must be voluntary. I would hate to live in a country where there were no benefits for a lifetime of work. If people want to continue work the evidence is there that it's good for health, even in old age.