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Occupational Medicine Advance Access originally published online on August 7, 2006
Occupational Medicine 2006 56(7):480-484; doi:10.1093/occmed/kql075
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© The Author 2006. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Return to work after ill-health retirement in Scottish NHS staff and teachers

Judith Brown1, W. Harper Gilmour2 and Ewan B. Macdonald1

1 Healthy Working Lives Research Group, Public Health and Health Policy Section, Division of Community Based Sciences, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, UK
2 Public Health and Health Policy Section, Division of Community Based Sciences and Department of Statistics, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, UK

Correspondence to: Ewan B. Macdonald, Head of Healthy Working Lives Research Group, Public Health and Health Policy Section, Division of Community Based Sciences, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, UK. Tel: +44 141 330 3720; fax: +44 141 330 4038; e-mail: e.b.macdonald{at}udcf.gla.ac.uk


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Key points
 Conflicts of interest
 References
 
Background Most major public and private sector pension schemes have provision for ill-health retirement (IHR) for those who become too ill to continue to work before their normal retirement age.

Aim To compare the causes, process and outcomes of IHR in teachers and National Health Service (NHS) staff in Scotland.

Methods A total of 537 teachers and 863 NHS staff who retired due to ill-health between April 1998 and March 2000 were mailed an IHR questionnaire by the Scottish Public Pensions Agency.

Results The response rate for teachers was 53% and for NHS staff 49%. The most common cause of IHR was musculoskeletal disorders for NHS staff and mental disorders for teachers. Teachers retired at a younger average age than NHS staff. Ninety-two per cent of NHS staff but only 11% of teachers attended occupational health services (OHS) prior to IHR. Eighteen per cent of NHS staff and 9% of teachers were offered part-time work by their current employer in response to their ill-health. Fifteen per cent of NHS staff and 5% of teachers were offered alternative work prior to retirement. Seventeen per cent of NHS staff and 36% of teachers subsequently found employment. Multiple logistic regression analyses showed the following variables as independent predictors of subsequent employment: occupational group, age group, sex, managerial responsibility and cause of IHR.

Conclusions Return to work after IHR suggests that some IHR could be avoided. Teachers had a higher rate of return to work and much less access to OHS.

Keywords      Ill-health retirement; NHS staff; return to work; Scotland; teachers


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Key points
 Conflicts of interest
 References
 
Provisions for ill-health retirement (IHR) exist in most major public and private sector pension schemes to ensure that employees are adequately provided for in the event of becoming too ill to continue in work before their normal retirement age. Relatively few studies of IHR have been conducted despite IHR being a significant health and socio-economic end-point. The level of IHR is now substantially higher than it was in the 1970s, particularly in the public sector [1]. The annual cost of each year's new IHRs in the UK is estimated to be ~£1 billion [1]. IHR has a heavy cost financially not only for the taxpayer but also for the employers who may be losing skilled staff, contributing to staff shortages, and for the employees who may not want to retire early and whose lifetime earnings are curtailed by early retirement. It has been recognized that being in appropriate work brings physical, mental and financial benefits and can promote confidence, independence and social inclusion [2], while conversely, being out of work for any length of time is detrimental to health and well-being [3].

The Scottish Public Pensions Agency (SPPA) is responsible for the provision of pensions to National Health Service (NHS) staff and teachers in Scotland. The gateway to IHR is determined by the criteria which each pension scheme sets for awarding ill-health benefits. If teachers are <60 years of age, they may apply for IHR provided there is evidence of permanent incapacity to continue working as a teacher. At present, there is no requirement to offer redeployment. There is no bar on a return to teaching, and under the provisions of the Scottish Teachers' Superannuation Scheme, the employment can be pensionable. Abatement will apply if the new salary plus pension exceed the level of the previous salary. To qualify for IHR and the early payment of benefits, NHS superannuation scheme members must show they are permanently incapable of efficiently discharging the duties of their employment. There is no bar to a person obtaining further employment in the NHS after receiving IHR, but they can only rejoin the scheme if they are <50 years old. If the new salary plus pension exceed the level of the previous salary, abatement will apply.

In Scotland, the award of IHR is decided by the SPPA. Occupational health services (OHS) may be involved in the process by advising the member about their potential eligibility and whether they should apply and subsequently in the provision of a medical report to the SPPA. In practice, the SPPA treat general practitioner and occupational health (OH) reports as alternatives in helping with the IHR decision process and they will also consider other medical reports. The SPPA relies on an independent pension scheme medical adviser to advise on eligibility for both schemes. The IHR application process is robust and is subjected to quality control procedures by the SPPA.

Previous IHR studies have included a study on the rates and causes of retirement due to ill-health in NHS staff in England, IHR among health care workers in Ireland and a cross-sectional survey of six organizations in the UK which included four public and two private large employers [4–6]. A recent follow-up study of NHS staff in England measured changes in health-related quality of life and employment status 1 year after early retirement because of ill-health [7]. Recently, Bowers and McIver undertook a study which surveyed 369 teachers who retired due to ill-health between October 1998 and September 1999 in England [8, 9] . The study examined the incidence of IHR, both nationally and regionally, and was set in the context of revised criteria for IHR. The study also revealed a profile of retirees. Another teacher study investigated IHR among school principals in Germany [10]. The purpose of this study was to compare the causes, process and outcomes of IHR in NHS staff and teachers in Scotland.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Key points
 Conflicts of interest
 References
 
Teachers and NHS staff who retired on ill-health grounds and received benefits from the Teachers' and NHS Superannuation Scheme in Scotland between April 1998 and March 2000 were eligible for inclusion. Participants were randomly selected by the SPPA to receive a postal, self-completion questionnaire in January 2002 with the aim of achieving a group size of 1400 individuals. The research team received no information on potential participants. The IHR questionnaire was accompanied by a prepaid addressed envelope, a letter from the SPPA assuring confidentially and a letter of invitation to respond from the University of Glasgow, detailing the purposes and potential uses of the information. All potential participants were sent one reminder letter 10 days after the initial correspondence. Questionnaires were not named or coded and therefore returned anonymously to Glasgow University. All participants were offered a telephone interview as an alternative. A total of 22 teachers and 31 NHS staff took up this opportunity.

Analysis of the completed questionnaires was undertaken on SPSS version 10.0. Responses were analysed using chi-squared and Student's t-test of significance. Following separate analyses of both sets of data [11,12], a comparison study was undertaken to highlight the main differences between the two groups of workers. The relative chance of subsequent employment was initially estimated by odds ratios (ORs) calculated for each predictive variable. Multiple logistic regression models including all possible predictors provided adjusted OR and their confidence intervals.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Key points
 Conflicts of interest
 References
 
In total, 2473 individuals (767 teachers and 1706 NHS staff) retired on ill-health grounds and received benefits from the Teachers' and NHS Superannuation Scheme in Scotland between April 1998 and March 2000. A total of 537 teachers and 863 NHS staff were sent the questionnaire in January 2002. A total of 282 teachers and 424 NHS staff completed the questionnaire, giving a response rate of 53% and 49%, respectively. There was a small but statistically significant difference between the NHS staff and teachers in terms of the retirement age due to ill-health (mean age for NHS staff = 53.9 years and for teachers = 52.2 years; t-test, t = 3.88; P < 0.001).

The most common cause of IHR was musculoskeletal disorders for NHS staff (38%) and mental disorders for teachers (37%) (Figure 1). No association was found between gender and cause of IHR in NHS staff.


Figure 1
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  		Figure 1. Cause of IHR in teachers and NHS staff. Percentage of teachers and NHS staff ill-health retirees by category of illness.

 
Large differences were observed between the use of OHS by NHS staff and teachers. Ninety-six per cent of NHS staff who took IHR had access to an OH advisor and 92% attended OHS prior to their retiral. Only 16% of teachers stated an OH advisor was available to them in their job and 11% attended OHS prior to IHR.

Many respondents indicated that the offer of part-time work or redeployment may have helped keep them in their job. During the period of time leading up to their retirement, 18% of NHS staff and 9% of teachers were offered part-time work in response to their ill-health. Fifteen per cent of NHS staff and 5% of teachers were offered alternative work. Forty-eight per cent of NHS staff and 37% of teachers were offered rehabilitation to help with ill-health prior to retirement. Only in a small number of cases was the rehabilitation organized by the workplace (NHS staff 16% and teachers 2%).

A significantly higher number of teachers had found subsequent employment after retiring—36% of responding teachers compared with 17% of responding NHS staff (P < 0.001). Of the 102 teachers who found subsequent employment since their retirement, 29 (28%) were undertaking jobs with a teaching-related task. Twenty-five of the 72 NHS staff (35%) working since IHR were undertaking jobs similar to their pre-retirement job, e.g. a nurse working in a private nursing home.

On unadjusted analyses, subsequent employment of participants after IHR was significantly associated with occupational group, sex (male), age group (<50), having had managerial responsibility prior to IHR and cause of IHR (mental disorders) (Table 1).


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  		Table 1. Predictors of subsequent employment of teachers and NHS staff after IHR

 
Stepwise logistic regression analyses identified occupational group (teacher/NHS staff), age group, sex, having had managerial responsibility and mental health as a cause of IHR as significant predictors of return to work after IHR (Table 1). The unadjusted OR for return to employment (teachers/NHS staff) was 2.77 (P < 0.001). This became 2.10 (P < 0.001) after adjustment. Thus, differences in age, causes of IHR, sex and managerial responsibility explained part of the difference in return to work between teachers and NHS staff but not all of it. Table 2 shows two examples of probabilities of returning to work after IHR based on the fitted logistic regression model. The probability of a male teacher, aged <50 years, having had managerial responsibility and retiring with a mental disorder obtaining work after IHR was 66% and 48% for a comparable NHS worker. The probability of a female teacher with no managerial responsibility, age 55+ and who retired with an illness other than a mental disorder returning to work after IHR was 14.8%, whereas for a similar NHS worker, the probability was 7.6%.


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  		Table 2. Examples of probabilities of subsequent employment after IHR from logistic regression model

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Key points
 Conflicts of interest
 References
 
The purpose of this study was to compare the causes, process and outcomes of IHR in Scottish teachers and NHS staff. The key findings were the significant differences in the causes of IHR, the utilization of OHS prior to IHR and the likelihood of finding subsequent employment after IHR.

Differences in the cause of IHR can be explained by occupational group. The major cause of IHR in NHS staff was diseases of the musculoskeletal system. Almost 70% of participating NHS staff were nurses/midwives or manual workers where physical demands are greater. In comparison, the most common cause of IHR in teachers was mental disorders. Stress in teachers has been well-documented and absenteeism and early retirals from the teaching profession may be proxy measures of stress [13]. Stress may account for a high proportion of mental disorders which would include depression and anxiety. No association was found between gender and cause of IHR in NHS staff, unlike that previously reported in teachers [12].

In this study, the difference in OH provision to teachers and NHS staff prior to retirement was huge. All 32 local authorities in Scotland claim to provide OHS to teachers but most do not provide open access to OHS [14] and this study would suggest that relatively few teachers who retired on ill-health grounds were referred to OHS for advice and support prior to retirement. A recent study in teachers showed that nearly half of the respondents found their job either very or extremely stressful [14] and that improved OH support may help to address this and ultimately keep teachers in work.

Considerably more NHS staff were offered part-time or alternative work prior to retirement. This may be because the options for redeployment for teachers are much less within a school teaching environment and/or because of lack of appropriate OH advice on work modification and job-retention strategies.

More teachers returned to work after IHR than NHS staff. Teachers are likely to be a highly intelligent homogenous group and there may be a greater motivation for this group of workers to work again. Teachers may be better equipped to find alternative work and adapt their skills to alternative work than the highly varied NHS staff group. The reason for greater return to employment after IHR in teachers may also be explained by the cause of IHR. More teachers retired with mental disorders than NHS staff and more NHS staff retired with musculoskeletal problems. Those who retire with a mental health problem may find other less mentally stressful work which they have the physical capability to do. Those who retire as a result of a physical disability may have been more limited.

In both sets of workers, a sizeable number of participants had returned to jobs that were similar to the job they had left. It is noteworthy that these retirees while still satisfying the criteria of the Teacher and NHS Pension Schemes and receiving an IHR pension were able to return to a job similar to the job from which they had retired. It is reasonable to question the adequacy of both OH provision and the current retirement decision process. A recent study found that changing medical criteria and introducing medical severance payment for those with temporary incapacity in a large pension scheme did reduce the rate and cost of IHR [15]. Several pension schemes, including the Civil Service Pension Scheme, are considering this two-tier system for which the criteria for the lower tier include permanency of ill-health for current job but for the upper tier for any gainful employment. This may be the way forward for many pension schemes and pension schemes should provide unambiguous criteria defining permanent incapacity. Updated guidance for occupational physicians on early retirement due to ill-health have recently been published with specific reference to pension schemes with eligibility criteria that include permanence of incapacity due to ill-health [16].

The predictors of return to work identified in this study could prove useful in identifying staff who are more likely to respond to rehabilitation and job-retention initiatives. In both occupational sectors, retiring with a mental disorder was a predictor of returning to work. Mental health problems and in particular anxiety and depression tend to improve with treatment [17–19] and many ill-health retirees may have had manageable health conditions where the outcome could be predicted to improve and early retirement need not have been the final outcome.

The strength of this study is that it directly compared NHS staff and teachers, who were members of pension schemes administered and regulated by the SPPA. Further, it followed up individuals after retirement and established if retirees had found subsequent employment. The response rate in this study was 53% for teachers and 49% for NHS staff. There could be some concern about non-response bias. Some potential participants may not have returned the questionnaire if they were working again despite being told the questionnaire was anonymous and due to the sensitivity of the information we were asking. All information in this study came from the questionnaire which was completed by the participant. No information was drawn from clinical records or Pension Scheme records; however, as the participants had only been retired for between 1 and 3 years, accuracy of recall would be expected to be good. Recall bias cannot be ruled out and it is possible, for example, that the NHS staff may remember better OH support due to multiple interactions over many years.

In the study, there was a significant difference in OHS provision to NHS staff and teachers. Teachers were seen less by OHS, had poorer support, had less rehabilitation and job-retention initiatives and had a higher rate of recovery from conditions judged as causing permanent incapacity by pension scheme medical advisors. The OH support to teachers needs to be improved. Over a quarter of teachers and one-third of NHS staff who have found subsequent employment since IHR are working in a similar role and so did not, it seems, have permanent incapacity. Subsequent employment after IHR might be regarded as a failure of the original employers' ability to support and modify work appropriately rather than of the process of IHR. This study has identified occupational and personal factors which are associated with return to work after IHR. Based on this study, further research could investigate to what extent targeted rehabilitation or OH initiatives could improve job retention in teachers with mental health problems.



   Key points
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Key points
Conflicts of interest
 References
 
  • Seventeen percent of NHS staff and 36% of teachers returned to work after ill health retirement.
  • IHR due to mental health problems was associated with subsequent employment.
  • Teacher access to occupational health services was poor.

 


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Key points
 Conflicts of interest
References
 
None declared.


   Acknowledgements
 
We thank Ralph Garden, Neville Mackay and the SPPA for financial support and for mailing the questionnaires to potential participants. We also acknowledge Karen Ritchie, Nundita Reetoo and William Thom for their help with the design of the study and Keith Murray for providing IT assistance.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Key points
 Conflicts of interest
 References
 

  1. Her Majesty's Treasury. Review of Ill Health Retirement in the Public Sector. London: Her Majesty's Treasury, 2000.

  2. Acheson D. Independent Inquiry into Inequalities in Health Report. London: The Stationery Office, 1998.

  3. Brenner MH. Unemployment and Public Health. Interim Report to the European Commission Directorate General Employment, Industrial Relations and Social Affairs DG EMPL/A/1 VC/2000/0022, 2000.

  4. Poole CJ. Retirement on grounds of ill health: cross sectional survey in six organisations in United Kingdom. Br Med J 1997;314:929–932.[Abstract/Free Full Text]

  5. Pattani S, Constantinovici N, Williams S. Who retires early from the NHS because of ill health and what does it cost? A national cross sectional study. Br Med J 2001;322:208–209.[Free Full Text]

  6. Gleeson D, Gallagher J. Ill-health retirement among healthcare workers in the Southern Health Board of the Republic of Ireland. Occup Med (Lond) 2005;55:364–368.

  7. Pattani S, Constantinovici N, Williams S. Predictors of re-employment and quality of life in NHS staff one year after early retirement because of ill health; a national prospective study. Occup Environ Med 2004;61:572–576.[Abstract/Free Full Text]

  8. Bowers T, McIver M. Ill Health Retirement and Absenteeism amongst Teachers. London: Department for Education and Employment, 2000.

  9. Bowers T. Teacher absenteeism and ill health retirement: a review. Camb J Educ 2001;31:135–157.[CrossRef]

  10. Weber A, Weltle D, Lederer P. Ill health and early retirement among school principals in Bavaria. Int Arch Occup Environ Health 2005;78:325–331.[CrossRef][Web of Science][Medline]

  11. Brown J, Reetoo KN, Murray KJ, Thom W, Macdonald EB. The involvement of occupational health services prior to ill health retirement in NHS staff in Scotland and predictors of re-employment. Occup Med (Lond) 2005;55:357–363.

  12. Brown J, Gilmour WH, Macdonald EB. Ill health retirement in Scottish teachers: process, outcomes and re-employment. Int Arch Occup Environ Health 2006;79:433–440.[CrossRef][Web of Science][Medline]

  13. Wilson V. Feeling the Strain: An Overview of the Literature on Teachers' Stress. The Scottish Council for Research in Education, Research Report No 109, 2002.

  14. Dunlop C, Macdonald EB. Teachers' Health and Wellbeing Study Scotland. Edinburgh: NHS Health Scotland, 2005.

  15. Wilson N. Changing medical criteria and medical severance payments may reduce the rate and costs of ill-health retirement. Occup Med (Lond) 2005;55:352–356.

  16. Poole CJ, Bass CM, Sorrell JE, Thompson ME, Harrison JR, Archer AD. Ill-health retirement: national rates and updated guidance for occupational physicians. Occup Med (Lond) 2005;55:345–348.

  17. Bakish D. New standard of depression treatment: remission and full recovery. J Clin Psychiatry 2004;62:5–9.

  18. Dietrich AJ, Oxman TE, Williams JW Jr et al. Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial. Br Med J 2004;329:602–607.[Abstract/Free Full Text]

  19. Whitty P, Gilbody S. NICE, but will they help people with depression? The new National Institute for Clinical Excellence depression guidelines. Br J Psychiatry 2005;186:177–178.[Free Full Text]


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