Metropolitan Police blues: protracted sickness absence, ill health retirement, and the occupational psychiatrist

Role of wider culture

As with all patients, what a police officer brings to the doctor is shaped by wider culture. A big feature of 20th century Western culture has been the rise in the authority assigned to medicotherapeutic ways of understanding the trials of life. Arguably, the contemporary concept of a person emphasises not resilience, as it once did, but vulnerability.1 A widening range of everyday experiences, including work, have come to be viewed as capable of inducing illness. “Stress,” until recently a folk category, has now gained the medical imprimatur of a real ailment: “work stress” is the number one cause of sickness absence in the United Kingdom.2

The number of people of employable age receiving incapacity benefit for longer than six months quadrupled to two million between 1981 and 2002. The Department of Work and Pensions states that 70% of patients receiving long term disability benefits have medically unexplained symptoms.3 Certification on mental health grounds is the leading cause of sickness absence in most high income countries, accounting for around 40% of lost time, with average time off sick for people with mental health problems at least twice that of workers certificated on physical grounds.4 Antidepressant prescribing, currently around 35 million prescriptions a year, has quadrupled since the early 1990s, but without a reduction in the reported population prevalence of depression.5 6

Role of police culture

The police officer also brings to occupational health aspects of organisational culture in which retirement and pension entitlement occupy a particular place. Officers are awarded a pension only on completion of 30 years’ service or if they retire on grounds of ill health. I was told that in the past the Metropolitan Police Service had seldom sacked officers for inefficiency or other problems but had often used ill health retirement instead. This had left a culture of entitlement regarding ill health retirement, yet officers were liable to see the role of occupational health as directed to reduce the pensions bill—and they often reminded me of the 2001 pledge of then home secretary, David Blunkett, to cut the bill. The hostility engendered when occupational health doctors contested claims for retirement on health grounds is shown by the regular reporting of doctors to the General Medical Council (in my case, three times).

At the time I was there 4.8% of the workforce was not doing full operational duties, with the loss of the equivalent of 180 police officers monthly because of stress related absence. There was a strong association between extended absence and work disputes, and a Metropolitan Police study has found an association between extended absence and the perception of the organisation as uncaring.7 Retirement on mental health grounds as a proportion of all ill health retirement had been rising—up to 46% in 2002-3. The service operated a recuperative duties scheme, whereby officers could return to work on limited duties on full pay for one year or longer.

Role of general practitioners

General practitioners officiate over the boundaries between sickness and health through their power to grant sickness certificates. Mental health problems are the commonest reason for writing a sickness certificate.8 The General Medical Council’s Good Medical Practice states that doctors must “respond to” patient preferences, not merely respect them.9 Doctors are reluctant to invalidate the illness claims of their patients. Although objective findings are present in only a few instances of sickness certification, and GPs believe that up to 40% of the certificates they issue may be dubious, many see their primary duty to the patient rather than to the Department of Work and Pensions or the employer. In one study half of participating GPs wanted to give up their certificating role.10 These findings are in line with the discussions I had with certificating GPs while working as an occupational psychiatrist, and show why certificates could continue to be issued regardless of occupational health assessments. Many GPs did not know about the police recuperative duties scheme.

Role of psychiatrists

The dominant biomedical culture of psychiatry conceives illness as a naturalistic process rather than being socially influenced. But psychiatric categories are not real diseases—validated facts of nature and biology (as is, say, tuberculosis or a fractured tibia)—but conceptual devices based on constellations of symptoms decided by committee. Diagnostic criteria for categories like depression or post-traumatic stress disorder distinguish poorly between situational distress and free standing disorder.11 12 Psychiatric formulations do not encompass the role of social engagement in buttressing personal adjustment and wellbeing. Their positivistic thrust is in tension with interpretative approaches that highlight the patient not as a mere recipient of illness but as an actor engaging with his situation. No diagnosis captures this active conceptualising and meaning making, and what flows from it. There is no objective test of whether a worker cannot resume work or will not.

Clinical findings in occupational health

The clinical interview and discussions about rehabilitation were much more straightforward when the officer had a “big” diagnosis such as schizophrenia, scarcely 1% of the 300 cases. These officers were clear that they wished to resume their police careers.

Interviews with the majority whose sickness certification was of “common mental disorders” often felt different. Many officers had re-evaluated past police service in the now negative light occasioned by present feelings of grievance or weariness. The not uncommon presence of a trade union representative in the room suggested that assessment by the occupational psychiatrist was regarded with mistrust rather than as an opportunity to discuss getting better with a specialist. Many felt estranged from the police service or the everyday role of a police officer. Once an officer saw ill health retirement as his preferred option, there was an imperative to maintain the illness presentation until the matter was decided.

Categories like post-traumatic stress disorder and “work stress” presume a single cause, yet psychiatric problems generally arise multifactorially. In at least three quarters of my assessments, officers were experiencing a range of stressors: conflict with other staff, being subject to management investigation, unresolved grievance procedures, marital discord, financial worries, children with drug problems. Some officers expressed a sense of loss of good name and momentum in their career, which disinclined them to resume, and lack of contact with the workplace over time itself generated a sense of distance.

Analysis of case material made clear a systemic complication of the functioning of NHS mental health services, undue prolongation of sickness absence, and fostering of secondary handicap. The psychiatrists and psychologists following up officers seemed to see diagnosis and treatment as having a life of its own (that is, separated from what else was going on in the patient’s overall situation, especially occupational). The officer sat passively at home between outpatient appointments, generally on antidepressants, waiting for the supposed cure of his anxiety or depression. There was little recognition, as sickness absence lengthened, of the potentially negative effects of a chronic sick role—an erosion of a sense of agency and competence, or the development of illness behaviours like apathy, increased preoccupation with symptoms, and avoidance of occupational health appointments. Some officers claimed disability benefits, which is a predictor of poor treatment outcomes.13 Clinic letters consistently failed to articulate treatment objectives in which the resumption of functioning represented by a negotiated return to work, if necessary through the recuperative duties scheme, would have a central place. The Healthcare Commission has criticised mental health services for their low expectation of what people can achieve in employment.14

Regarding treatment of post-traumatic stress disorder, professionally directed attention to the past, sometimes years previously, and to “emotion,” seemed antitherapeutic rather than curative in these officers. My experience was that only a few officers absent with post-traumatic stress disorder ever fully resumed their careers: the definitive role of traumatic stress clinics was not to produce a fit officer but to support his wish for ill health retirement and pension. This is in contrast to a study by Neal and colleagues of 70 UK armed services personnel referred for assessment of possible post-traumatic stress. Symptoms of depression predicted disability, including work, but symptoms of post-traumatic stress disorder did not.15

Officers submitted supporting psychiatric reports, mostly from the NHS but also from private psychiatrists seen once. A consultant psychiatrist might write in to recommend ill health retirement only a few weeks after an officer had first been referred to his service, despite no previous psychiatric history and positive evidence of many years of robust functioning, including police commendations. Rehabilitation was not mentioned. One consultant gave the wear and tear of an officer’s entire police career as the criterial stressor event for his post-traumatic stress disorder, for which ill health retirement was recommended. Overall, these reports seemed largely to be recycling in medical language what the officer said he wanted.

To qualify for retirement on psychiatric grounds an officer must be deemed “permanently disabled” from resuming the full duties of a police officer, a test that in my clinical judgment only a few could pass. The number one predictive factor regarding a return to work and career was whether the officer wanted to, which no psychiatric formulation captures.16

Conclusions

Although I do not want to play down the experiences of these officers, the medicalisation of non-specific symptoms, allied to social rewards that create perverse incentives, reliably prolongs disability. The longer sickness absence lasts, the more the secondary handicap of a chronic sick role is the main therapeutic challenge, and the harder it is for an officer to contemplate resuming his career. Psychiatry has a subjective emotional focus, yet as time passes the clinically urgent question is not “How are you feeling?” but “What do you have to do to get back to normal?” The evidence is that in most situations the benefits of work for an individual’s mental health outweigh any risks.17 Psychiatric and psychology services have failed to put graded normalisation back to customary social roles, notably work, at the heart of therapeutic objectives from the start. For their part GPs sign sickness certificates without setting goals and often without knowledge of recuperative work schemes. They are understandably uneasy about taking responsibility for a scheme that is largely patient led.

Certification is diagnosis based, but static biomedical categories cannot capture problems rooted in a situation, with its own dynamic, rather than in a “mental state.” In much sickness absence based on workplace stress, the problem is really an operational or staffing one: dislocation to a psychiatric arena can paralyse the practical problem solving required to normalise the situation.

The basic concept in rehabilitation must be early intervention. Management systems need to resolve disputes and grievances promptly, before they fester. More recently the Metropolitan police have taken some of the heat out of the occupational health assessment process by shifting the final decision on ill health retirement to external assessors. There needs to be much closer working between occupational health departments and NHS services, starting early in the sickness absence period. The switch in sickness certification that focuses on what a person can do rather than what he cannot, following the Black report, is positive.18 But above all we need a culture change in mental health service practice.