International Centre for Health and Society, Department of Epidemiology and Public Health, University College London Medical School, 1 - 19 Torrington Place, London WC1E 6BT

Jane Ferrie
Senior Research Fellow
International Centre for Health and Society, Department of Epidemiology and Public Health, University College London Medical School, 1 - 19 Torrington Place, London WC1E 6BT, and Population Research Unit, Department of Sociology, University of Helsinki, Finland

Pekka Martikainen
Senior Research Fellow
International Centre for Health and Society, Department of Epidemiology and Public Health, University College London Medical School, 1 - 19 Torrington Place, London WC1E 6BT

Martin Shipley
Senior Lecturer in Medical Statistics
International Centre for Health and Society, Department of Epidemiology and Public Health, University College London Medical School, 1 - 19 Torrington Place, London WC1E 6BT

Michael Marmot
Director, International Centre for Health and Society
Department of Psychiatry, Basic Medical Sciences Building, Queen Mary, University of London, Mile End Road, London, E1 4NS

Stephen Stansfeld
Professor of Psychiatry
Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BSS 2PR

George Davey Smith
Professor of Clinical Epidemiology

Author for correspondence:

Jane Ferrie,
e-mail: j.ferrie@public-health.ucl.ac.uk
telephone (+44 171) 504 5643
fax (+44 171) 813 0288

Abstract

Objective - To determine whether employment status following job loss due to privatisation influences health and health service use, and whether these associations are explained by changes in financial strain, psychosocial measures or health-related behaviours.

Design and Setting - One department participating in the Whitehall II study, a prospective cohort of civil servants, was sold to the private sector. Data were collected before and 18 months post-privatisation.

Participants - All 666 Whitehall II participants employed during baseline screening in the department to be privatised.

Main outcome measures - Health and health service outcomes associated with insecure re-employment, permanent exit from paid employment and unemployment post-privatisation were compared with outcomes associated with secure re-employment.

Results: Insecure re-employment and unemployment were associated with relative increases in minor psychiatric morbidity, mean difference 1.56 (95% confidence intervals intervals,1.0 - 2.2) and 1.25 (0.6 - 2.0) respectively. Four or more consultations with a General Practitioner in the last year was associated with insecure re-employment, odds ratio 2.04 (1.1 - 3.8) and unemployment 2.39 (1.2 - 4.7). Health outcomes for respondents permanently out of paid employment closely resembled the securely re-employed, except for a substantial relative increase in longstanding illness, odds ratio 2.25 (1.1- 4.4). Financial strain, and change in psychosocial measures and health-related behaviours accounted for little of the observed associations. Adjusting for change in minor psychiatric morbidity attenuated the relationship between insecure re-employment or unemployment and General Practitioner consultations by 26% and 27% respectively.

Conclusions: This study provides reasonable evidence that insecure re-employment and unemployment post-privatisation result in an increase in minor psychiatric morbidity. Furthermore the results suggest that insecure re-employment and unemployment post-privatisation are associated with increased General Practitioner consultations, possibly because of increased minor psychiatric morbidity.

Introduction

The public sector in the United Kingdom traditionally was immune to the pressures of the marketplace and among it’s main attractions were job security, a career and good conditions of service. However, much of this changed during the 1980s when the United Kingdom led the way among industrialised countries in moves away from planned public ownership and provision.[1] Privatisation of the first public service came in 1984. By the end of 1997 most public utilities had been privatised, and currently privatisation is being introduced into education, health care, transport, and central and local government. The future privatisation of the executive functions of government came onto the agenda with the introduction of the ‘Next Steps’ programme in August 1988. Early in the restructuring, one of the twenty departments participating in the Whitehall II study, the Property Services Agency, was sold to the private sector.

Whitehall II is an ongoing, prospective study of the health of civil servants and baseline data were collected prior to any indication of major restructuring in the Civil Service. It is thus ideally placed to address some of the methodological limitations of previous studies of the health effects of workplace closure. Rumours of the forthcoming privatisation reached the work force 2 - 3 years before the sale and during this ‘anticipation’ phase there was a deterioration in self-reported health both compared to baseline and, crucially, compared to other departments in the Whitehall II study.[2] By the ‘pre-termination phase’, immediately before the sale, both self-reported morbidity and physiological risk factors had increased relative to respondents in the control departments.[3] These increases in morbidity were not explained by changes in other psychosocial work characteristics, or changes in health-related behaviours.[4]

In this paper we examine the effects on health and General Practitioner consultations of employment status 18 months after the privatisation and determine whether associations can be explained by changes in financial strain, psychosocial measures and health-related behaviours.

Methods

The privatisation of the Property Services Agency, responsible for the design, construction and maintenance of all government buildings, was complete by the end of 1993. Between April 1990 and July 1991 the Property Services Agency was split into 6 stand-alone businesses. The majority of Whitehall II respondents in this department at baseline were in Projects division, the design and construction side, sold to Tarmac plc in December 1992.[5] Following the privatisation all employees lost their original jobs.

The Whitehall II study

The target population for the Whitehall II study was all London-based office staff working in 20 Civil Service departments between late 1985 and early 1988. With a response rate of 73%, the final cohort consisted of 10,308: 6,895 men and 3,413 women. Although mostly white-collar, respondents covered a wide range of grades. The baseline screening of the Whitehall II cohort involved a clinical examination and a self-administered questionnaire which contained sections on demographic characteristics, health, lifestyle, and work characteristics.[6]

The Property Services Agency Study

A study specifically to investigate effects of the privatisation commenced in 1994. The study population was all 666 (153 women and 513 men) Whitehall II respondents working in the Property Services Agency at baseline screening. In addition to utilising baseline data from Whitehall II, the study gathered follow-up data by self-administered questionnaire from the study population 18 months post-privatisation, 8 - 9 years after baseline screening. The work presented in this paper utilises the baseline survey and data from the follow-up questionnaire. Unfortunately, due to cost constraints, data collection could not be extended to the whole Whitehall II cohort.

Measures

Personal details Items drawn from the baseline and follow-up questionnaires include age, marital status, Civil Service employment grade at baseline and employment status 18 months post-privatisation.

Health outcomes and General Practitioner (General Practitioner) consultations Self-reported health outcomes from the baseline and follow-up questionnaires cover; health over the last year self-rated as average, fair or poor versus good or very good, presence of longstanding illness, number of symptoms in the last fortnight (from a checklist of 17), number of health problems in the last year, minor psychiatric morbidity assessed using the 12-item General Health Questionnaire, and number of General Practitioner consultations in the preceding 12 months (follow-up questionnaire only).

Exposure measures Employment status 18 months post-privatisation was derived from responses to the follow-up questionnaire. The question ‘How secure do you feel in your present job?’ facilitated division of the employed into two groups, those who were ‘secure’ or ‘very secure’ and those who were ‘not very secure’ or ‘very insecure’. Respondents not in paid employment were divided according to their response to the question ‘Would you like to find another job?’. Those seeking work were classified as unemployed and those not seeking work as permanently out of paid employment. The final four categories were as follows: (i) secure re-employment, (ii) insecure re-employment, (iii) unemployed, and (iv) permanently out of paid employment.

Explanatory factors (i) Negative affectivity This trait was assessed using the five negative affectivity items from Bradburn’s Affectivity Balance Scale.[7] (ii) Financial strain: Responses to two questions from Pearlin’s list of chronic strains [8] were combined. Scores ranged from 0 to 8. Questions covered problems with paying bills and buying the kind of food and clothing the respondent felt s/he and the family should have. (iii) Psychosocial measures: Perception of low ability to influence one’s health (external locus of control) and two or more adverse life events in the last year, versus 0 or1, were investigated in all employment status groups. For those in employment four other psychosocial work characteristics were examined. Decision authority, skill discretion and job demands were adapted from the Job Content Instrument of Karasek.[9] Work social support comprised three components; support from colleagues, support from supervisors, and clarity and consistency of information from supervisors. All the questions required responses on a four-point scale from ‘often’ to ‘never/almost never’. Each work characteristic scale was divided into tertiles, and for analysis, change from tertile at baseline to a more adverse or beneficial tertile by follow-up formed the explanatory factor. Those who experienced adverse change were compared with those who experienced no change or beneficial change and vice versa. (iv) Health-related behaviours: Three health-related behaviours were investigated, alcohol consumption over the recommended limits, smoking and exercise. All explanatory factors, except negative affectivity, were measured at baseline and follow-up.

Statistical analysis

The overall aim of the analyses was to determine whether change in morbidity between baseline and follow-up differed between respondents in the four employment status categories post-privatisation. In the absence of a control group, who had not experienced privatisation, those in the most favourable labour market category (secure re-employment) formed the reference group.

Sex differences for all measures were small (analyses not shown) and the sexes were thus combined for further analysis. Initially, baseline characteristics of respondents who comprised the employment status groups post-privatisation were compared. For continuous variables, linear regression (General Linear Models procedure in SAS) was used to produce adjusted means with 95% confidence intervals, with adjustment being made consecutively for age, employment grade, marital status and the baseline level of the variable of interest. Results for continuous variables compare the exposure groups with the reference group in terms of adjusted mean differences. For dichotomous variables, logistic regression (LOGIST procedure in SAS) was used with results presented as odds ratios with 95% confidence intervals.

Following the analysis of morbidity measures and General Practitioner consultations, potential mediators of increases in these outcomes were identified. These were explanatory factors which had changed between baseline and follow-up, relative to the reference group, at conventional levels of statistical significance (p<0.05). Such factors were included in the final model for each health outcome. Models were also adjusted separately for negative affectivity, which is characterised by a disposition to over-report negative events and experience chronically high levels of distress. The datasets used in these analyses only include respondents who have data for the health outcome of interest and the potential mediator(s), hence, odds ratios or differences may differ slightly.

Results

Employment status

Of the 666 respondents in the Property Services Agency at baseline, 541 (81%) responded to the follow-up questionnaire and, excluding the deceased, non-response was 17%. Non-responders were younger than responders and a smaller proportion did vigorous exercise at baseline. The 539 respondents who provided usable data were categorised by employment status 18 months post-privatisation - Table 1. 219 (41%) of respondents were no longer working and of the 320 (59%) in employment, 155 (48%) felt insecure or very insecure in their jobs. Less than 10% of respondents in the study population transferred to the purchaser.

Baseline differences - Table 2

In general, there was greater morbidity and a poorer profile of psychosocial factors and health-related behaviours at baseline among respondents in the less favourable labour market positions post-privatisation. Tests of heterogeneity between the groups were not statistically significant for psychosocial factors and health-related behaviours, but were statistically significant for all health measures, except longstanding illness. However, analyses of health outcomes post-privatisation adjusted for the baseline values of all the health measures and all the potential explanatory variables were very similar to the results presented in Table 2

Health outcomes and General Practitioner consultations - Table 3

Insecure re-employment and unemployment After adjustment for baseline measures, morbidity was greater among respondents insecurely re-employed or unemployed post-privatisation than among those securely re-employed. For minor psychiatric morbidity and consulting one’s General Practitioner four or more times in the last year differences were statistically significant.

Permanent exit from paid employment Among respondents permanently out of paid employment outcomes for health self-rated as average or worse and number of symptoms in the last fortnight compared favourably with the reference group. There was little difference in number of health problems in the last year, but the relative difference in longstanding illness was statistically significant. Levels of minor psychiatric morbidity were very similar in the two groups but, although General Practitioner use was considerably raised, the relative difference was not statistically significant.

Potential explanatory factors - Table 4

All the less favourable employment status outcomes were associated with a relative increase in financial strain, which was statistically significant in the unemployed. Relative to respondents securely re-employed, those in insecure re-employment generally experienced adverse changes in other psychosocial work characteristics, which were statistically significant for decision authority and skill discretion. Overall, health-related behaviour profiles associated with the less favourable labour market outcomes were more favourable than those for the securely re-employed, including a substantial relative increase in taking vigorous exercise among unemployed respondents. However, there was a considerable relative increase in smoking among respondents permanently out of paid employment.

Potential explanations - Table 5

Adjustment for negative affectivity had a negligible effect on the relationship between permanent exit from paid employment and longstanding illness. The only potential mediator which attenuated the relationship between insecure re-employment and minor psychiatric morbidity was adverse change in decision authority (6%). Financial strain attenuated the relationship between unemployment and minor psychiatric morbidity by 9%.

Adjustment for minor psychiatric morbidity attenuated the relationship between employment status and General Practitioner consultations in the last year by 26% among respondents in insecure re-employment and by 27% among the unemployed. Financial strain attenuated the relationship between unemployment and General Practitioner consultations by 9%, but adjustment for increased exercise strengthened the association by 11%. The effect of adjusting for all the potential mediators and negative affectivity together shows that these effects are partially independent and partially overlapping.

Discussion

Methodological considerations

Many workplace closure studies have been limited by their inability to collect data from a period of secure re-employment before any rumour of job loss. Whitehall II has personal details, data on health status, psychosocial measures, and health-related behaviours which were collected before privatisation of the Property Services Agency was anticipated. Previous history of ill-health is often the strongest predictor of subsequent morbidity. Comparison of paired data for individuals from the baseline screening, a phase of secure employment, with those collected 18 months post-privatisation enabled the study to determine changes related to loss of secure employment to be separated from the effects of prior health status and other demographic factors.

The combination of secure employment data and a longitudinal design facilitated use of an analytic strategy equivalent to an intention-to-treat analysis used in clinical trials. Thus, the analyses included all participants who were in the Property Services Agency at baseline and from whom data were collected at follow-up. This means the cohort was entirely unselected and included respondents who left the Property Services Agency workforce before any rumour of privatisation and those who left or transferred to another department during the process, but for reasons other than privatisation. Including respondents who had little or no exposure to privatisation, or were relatively unaffected by it, results in conservative estimates of effects, but avoids overstating its impact.

The study’s weakest points are the absence of a control group and potential selection into re-employment. However, use of the securely re-employed, who also went through the privatisation, as the reference group is likely to result in further underestimation of effects. Furthermore, adjustment for all the morbidity measures and potential explanatory factors at baseline had little effect on health outcomes post-privatisation (data not shown), indicating that selective re-employment is unlikely to explain our findings fully.

The generalisability of findings from most occupational studies is limited by the subjects, often a relatively homogeneous group working in one particular field or organisation. Similarly, in this study, in addition to being white-collar, many of the respondents were specialised professional and technical staff in the construction industry. However, the Property Services Agency also employed a considerable number of administrators and general office staff such as personal assistants, secretaries, personnel and welfare officers, clerks and messengers who make it equivalent to many office-based settings both in the public and private sector.

Self-reported morbidity

Respondents who found secure re-employment post-sale enjoyed the best self-reported health, while those who were insecurely re-employed or unemployed had the worst outcomes for most measures, although differences were not statistically significant. Among those permanently out of paid employment self-reported health outcomes were similar to those for respondents in secure re-employment, except for longstanding illness which was much higher than in any other group. Longstanding illness has been shown in other studies to be associated with permanent exit from paid employment, particularly at times of high unemployment.[10]

Minor psychiatric morbidity

Most workplace closure studies,[11][12][13][14] have compared mental health in the unemployed with that for the re-employed. With one exception,[13] such comparisons show the re-employed to have better mental health than the unemployed, although long-term unemployment narrows or eliminates this difference. The problem with such comparisons is that differences may be due to the selective re-employment of those with better mental health.[15][16] Post-privatisation in this study, however, the re-employed were divided into those whose re-employment was secure and those whose was insecure. This division showed that change in minor psychiatric morbidity was statistically significant among the insecurely re-employed compared with those in secure re-employment. This relative increase is commensurate with Burchell’s finding that increased depression scores in unemployed men are not reduced by re-employment in an insecure job.[17] Unsatisfactory re-employment post-closure among male steel workers[18] and car workers[14] increased depression compared with satisfactory re-employment, while values for the unemployed fell between.[18] Perceived job insecurity has also been associated with an increased risk of minor psychiatric morbidity in cross-sectional studies in different occupational groups, predominantly white collar.[19][20][21]

Minor psychiatric morbidity was associated with unemployment 18 months post-privatisation. Two recent reviews of the effect of unemployment on health conclude that data from longitudinal studies show unemployment to be associated with deteriorating mental health,[22][23] although it is unclear how long such effects persist.[23] The mean General Health Questionnaire score for respondents permanently out of paid employment was almost the same as for the securely re-employed. A workplace closure study among car workers showed that one year post-closure the securely re-employed and the retired had similarly low levels of depression,[14] as did older ship builders who accepted early retirement on full-pay.[24]

General Practitioner consultations

Four or more General Practitioner consultations in the last year showed a strong positive association with all the less favourable labour market positions 18 months post-privatisation. This association was statistically significant for the insecurely re-employed and the unemployed, which were also the labour market positions associated with greater levels of self-reported morbidity. Other studies which have data on this outcome have shown insecure re-employment[25][26] and unemployment[27][28][29][30] to be associated with increased General Practitioner consultations. Adjustment for minor psychiatric morbidity showed that over a quarter of the increase among the insecurely re-employed and the unemployed appears to be attributable to increased minor psychiatric morbidity.

Explanations based on psychosocial factors, financial strain and negative affectivity

As in many other studies, financial strain was associated with unemployment and explained 9% of the association between unemployment and increased minor psychiatric morbidity. Most other work has shown relationships between unemployment and psychological symptoms to weaken substantially or disappear on adjustment for financial hardship,[31] and General Health Questionnaire scores to be dependent on proportional change in family income.[32] However, Whelan has shown that, although household heat, food, clothing and debt poverty have a large role in mediating the impact of unemployment on minor psychiatric morbidity, unemployment continues to have a substantial independent effect in the unemployed individual.[33]

Adverse changes in decision authority explained 6% of the association between minor psychiatric morbidity and insecure re-employment post-privatisation. No other study of workplace closure or redundancy seems to have looked at changes in other psychosocial work characteristics on re-employment post closure. However, a recent Finnish study found adjustment for decreased participation in decision making explained 19% of the association between major versus minor downsizing and medically-certified sickness absence,[34] but a study among miners found that job control did not moderate the adverse effect of job insecurity on psychological strain.[35]

Adjustment for negative affectivity had little influence on the findings, although it is plausible that respondents who report their employment as being insecure may also give adverse reports about other aspects of their life. Measures of negative affectivity may be rather limited in their ability to address this issue[36] however, and future work on our cohort which will allow objective health indicators to be examined will therefore be valuable.

Explanations based on health-related behaviours

None of the workplace closure studies have reported data on exercise. Cross-sectional studies have found the unemployed to report levels of physical activity comparable to those for the employed.[37][38] However, a cross-sectional population study in Sweden found that those unemployed for 1 year or more had raised levels of physical activity compared with men who had experienced little unemployment[39] and a study of male construction workers in Finland found a relative increase in exercise among those unemployed long-term (<24 months).[40] Exercise data from this study seem to indicate that the non-employed were spending some of their increased time in physical activity. Most sports and leisure facilities in the United Kingdom have special rates for unemployed and retired people to encourage uptake in these groups. Adjustment for exercise showed that General Practitioner consultations among the unemployed would have been greater by 11% had this group not taken up this health enhancing behaviour.

Policy implications

Our findings show the loss of secure re-employment following privatisation is associated with increases in minor psychiatric morbidity in the insecurely re-employed and unemployed, and longstanding illness among those permanently out of paid employment which cannot be explained by changes in financial strain, psychosocial factors or health-related behaviours. This suggests that employment status post-privatisation has a direct effect on minor psychiatric morbidity and longstanding illness, or that effects are mediated through factors not considered in this paper. In addition to this increase in individual morbidity, the loss of secure public-sector employment adds to National Health Service costs through increased General Practitioner consultations, which our results suggest are partly related to the increased minor psychiatric morbidity associated with privatisation.

Contributors

Jane Ferrie organised the data collection at follow-up, carried out the analysis, wrote the original and successive drafts of the paper. Pekka Martikainen helped interpret the data and commented on all drafts of the paper. Martin Shipley advised on the analysis and drafts of the paper. Michael Marmot designed and directs the Whitehall II study. Stephen Stansfeld commented on drafts of the paper. George Davey Smith designed the sub-study presented in this paper and commented on all drafts of the paper. Jane Ferrie will act as guarantor for the study.

Acknowledgements

We thank all participating civil service departments and their welfare, personnel, and establishment officers; the Occupational Health and Safety Agency; the Council of Civil Service Unions; all participating civil servants in the Whitehall II study; and all members of the Whitehall II study team.

Funding

The work presented in this paper was supported by the Economic and Social Research Council (R000235083). The Whitehall II study has been supported by grants from the Medical Research Council; British Heart Foundation; Health and Safety Executive; Department of Health; National Heart Lung and Blood Institute (RO1-HL36310), US, NIH: National Institute on Aging (RO1-AG13196), US, NIH; Agency for Health Care Policy Research (RO1-HS06516); and the John D and Catherine T MacArthur Foundation Research Networks on Successful Midlife Development and Socio-economic Status and Health. Pekka Martikainen is also supported by the Academy of Finland (grant 48600) and the Signe and Ane Gyllenberg Foundation. Martin Shipley is supported by the British Heart Foundation. Michael Marmot is a Medical Research Council research professor. George Davey Smith was a Wellcome Fellow in Clinical Epidemiology when baseline data for this study were collected.

Ethical approval

Ethical approval for the Whitehall II study was obtained from the University College London Medical School Committee on the ethics of human research.

Competing Interests

None.

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Table 1 Distribution of PSA respondents by employment status 18 months after the privatisation
 

*Includes respondents who retired from the Civil Service at the usual age of 60.

Table 2 Means and percentages* at baseline for demographic factors, negative affect and outcomes measures by employment status 18 months post-privatisation
 

*All means and percentages are adjusted for age (except age), and sex.

*All analyses of health measures are adjusted for sex, age, grade, marital status and baseline value of the outcome of interest.

†Analyses of GP visits are adjusted for sex, age, grade and marital status.

n/a Not applicable.

*Effects are adjusted for sex, age, grade, marital status and, apart from life events in the last year, for baseline value of the outcome of interest.

*Table 5 shows the adjusted odds ratios or adjusted differences between respondents permanently out of paid employment, insecurely re-employed, or unemployed compared with securely re-employed respondents. All odds ratios and differences are adjusted for age, sex, grade, marital status and baseline value of the outcome of interest. Fully adjusted odds ratios and differences are also adjusted for the factors in the table.

†% change in the log of the odds ratios or the differences between the adjusted and unadjusted.