Sick Note: A History of the British Welfare State 
by Gareth Millward.
Oxford, 230 pp., £30, September 2022, 978 0 19 286574 8
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If Ifall sick, my employer will pay me my full salary for 26 weeks – a bit more than £1000 a week before tax and National Insurance deductions – and then half pay for a further 26 weeks. For the first seven days of my illness I can ‘self-certify’; after that I have to go to my GP and get what are, ironically, called ‘fit notes’ at regular intervals. If an employer doesn’t have an occupational sick pay scheme, they only have to pay workers Statutory Sick Pay – £99.35 a week for up to 28 weeks. To qualify for sick pay, your earnings must exceed £123 a week (which excludes many part-time workers) and you can’t claim anything for the first three days. Precarious workers – agency staff, or those on casual or zero-hours contracts – are entitled to Statutory Sick Pay, but in practice many fail to claim it. Statutory Sick Pay in the UK is particularly ungenerous, replacing less than 20 per cent of average earnings; among advanced economies, only the US and South Korea offer something worse: no mandatory sick pay at all. In many countries, between 70 and 100 per cent of a sick worker’s income is replaced through mandatory sick pay or sickness benefits, or a combination of both (Norway tops the table).

Unsurprisingly, access to occupational sick pay schemes tracks other sorts of privilege. In 2014, a survey commissioned by the Department for Work and Pensions found that 56 per cent of blue-collar employees had access to one; among white-collar employees, the figure was 73 per cent. Those on temporary or casual contracts were more likely than permanent employees to have to rely on Statutory Sick Pay, women more likely than men, Black workers more likely than white, disabled than not disabled, part-time than full-time.

If you are unable to work because of illness but ineligible for sick pay, you can still qualify – providing you’ve made sufficient National Insurance contributions – for Employment and Support Allowance, part of the puny rump of insurance-based benefits in the UK system. A Work Capability Assessment will judge whether or not you are likely to return to work (the budget included a promise to scrap this assessment, but that won’t actually happen until 2026 at the earliest). You are considered to be unable to work if you ‘cannot press a button (such as a telephone keypad) with either hand or cannot turn the pages of a book with either hand’; ‘cannot convey a simple message, such as the presence of a hazard’; or have, ‘on a daily basis, uncontrollable episodes of aggressive or disinhibited behaviour that would be unreasonable in any workplace’. For those judged capable of returning to work, the allowance is £77 a week, for up to a year. For those deemed incapable, the allowance is £117.60 a week indefinitely. These sums are clearly not enough to live on. It’s possible to claim Universal Credit at the same time, but an amount equivalent to Employment and Support Allowance will be deducted from it.

Universal Credit is now the benefit of last resort for working-age people in the UK. It replaces six older benefits and tax credits – Housing Benefit, Income Support, income-based Jobseeker’s Allowance, income-related Employment and Support Allowance, Child Tax Credit and Working Tax credit – and was supposed to simplify the system. It’s means-tested: the income and savings of the claimant and their partner are taken into account. If you have more than £16,000 in savings and investments, you can’t claim. Calculating payments is wildly complicated – the government recommends the use of an online calculator such as – but if you’re single and over 25 with no savings, the standard allowance is £77 a week.

Universal Credit also offers payments for those who act as carers, for childcare and housing costs, though this is pretty stingy. If you’re eligible for a one-bed flat in Camberwell, South London, where I live, you would get an extra £264.66 a week; there’s currently nothing on Rightmove at that price in the area. There are also extra payments if you have children (£56 per child per week), but since 2017 payments have only been made for the first two children in a family, though there are exceptions, such as for a subsequent child conceived by rape. Though the benefit cap – introduced by the coalition government in 2013 to try to ensure that no household would be better off on benefits than in work – doesn’t apply to claimants assessed as unable to work, Universal Credit is often still inadequate. Stories abound of claimants with long-term health conditions and disabilities who are forced to skip meals or turn off the heating. The Work Capability Assessment has been repeatedly criticised as incompetent, over-complicated, humiliating and cruel. Its replacement is unlikely to be an improvement.

During the pandemic, 2.8 million extra households unexpectedly became reliant on social security, and sick pay became a public health issue. The inadequacy of the welfare system was soon obvious: many essential workers who couldn’t work from home were only eligible for Statutory Sick Pay; some couldn’t afford to stop work even if they tested positive for Covid. The government temporarily made Statutory Sick Pay payable from the first rather than the fourth day of illness, and claimable by those who were self-isolating as well as those who were sick. To compensate for its low level, £500 emergency self-isolation payments were introduced for those on low incomes, and you could get an ‘isolation note’ just by filling in a form online, no fit note required.

There was also a huge jump in claims for Universal Credit: in the four weeks to 9 April 2020, 1.2 million people began a claim, about a million more than would usually do so in a four-week period; a similar number began claims the following month. Most of these people weren’t sick, just unemployed, but long Covid will have resulted in more long-term sickness claims – last summer, two million people were reporting symptoms, and 16 per cent of them said their ability to undertake day-to-day activities was ‘limited a lot’. At the beginning of the pandemic, the government made Universal Credit more generous: lifting the standard allowance by £20 a week, as well as increasing local housing allowances and suspending some deductions. Those who were sick or self-isolating because of Covid didn’t have to get a fit note or Work Capability Assessment; reassessments of disabled claimants were suspended. All these changes were soon reversed.

The​ British welfare state is often seen as having followed a straightforward trajectory from the postwar Labour government to the Thatcher governments of the 1980s. The left tells a story of decline: the universal, cradle-to-grave welfare state was destroyed by the purveyor of ‘Victorian values’. For the right it’s the opposite story: the inefficiencies of the bloated state and the dependency society were finally punctured by Thatcherite crusaders. Historians, unsurprisingly, contest such simple narratives – as Gareth Millward does in his history of the welfare state as charted by the fortunes of the sick note.

The sick note is the keystone in the arch between two pillars of William Beveridge’s wartime plan for the welfare state: universal systems of health and social security. Medical care free at the point of use would keep workers healthy and productive, returning them to work after illness or injury. Social security would ensure that they took the necessary time off for rehabilitation and recuperation. All this would enable them to work more productively and for longer. Some form of gatekeeping would be needed, however, to make sure that those who said they were sick weren’t malingering. The Attlee government enacted most of Beveridge’s proposals. On 5 July 1948, the new NHS, National Insurance and National Assistance systems came into effect. Everyone was entitled to medical treatment free at the point of use, and a worker who fell ill could – after a three-day wait and if he or she had enough National Insurance stamps – claim sickness benefit from the state. The gatekeeper would be the doctor providing the sick note.

Before the Second World War, sick notes were in widespread use by friendly societies – working-class organisations common in Britain from the late 18th century that offered sickness and funeral benefits to members who made regular contributions to a fund – and trade unions. Smaller friendly societies often used ‘sick visiting’ as an alternative to sick notes, but repeated home check-ups were more expensive than being signed off by a doctor, and larger schemes tended to favour the sick note, as did government compensation and social insurance schemes before 1945.

Oddly, Millward doesn’t mention that Beveridge didn’t want the sick note to be used as a form of gatekeeping: he wanted to use friendly societies, so that sick visiting could continue. In a debate on the Labour government’s plans for National Insurance in 1946, Beveridge said that it ‘did frankly send a chill to my heart to realise that it was contemplated that the only way in which most people would get their sickness benefit would be through the post.’ Working through friendly societies would guard against malingering, but it would also make the system more humane: ‘I am not going to say a word … to suggest that civil servants are not human … But while civil servants are perfectly human, the unfortunate fact is that anything as big as the civil service, merely because of its size, tends to become inhuman.’

Labour decided against using the friendly societies. The system would instead be run by bureaucrats. A panoply of new forms were introduced: GPs issued the Med 1 to sign an employee off and the Med 2B to authorise them to return to work (there were also Med 2As, Med 5s and Med 6s). In theory, filling in all these forms enabled doctors to keep an eye on sick workers, catching malingerers and ensuring proper recuperation; what often really happened, certainly in the case of minor ailments, was that GPs held a single consultation with the patient and issued a Med 1 and Med 2B simultaneously. They complained about ‘form-mongers’ wasting their time. GPs were jealous of their independence, and many didn’t want to be the government’s gatekeepers; as one group of doctors put it in 1965, ‘the boss knows the workers he can trust and those who are scrimshankers. It is not up to us to arbitrate and decide if a worker is telling the truth.’ In any case, the evidence for a patient’s malady was often nothing more than ipse dixit – what he or she said. In the 1960s, the British Medical Journal began to publish studies showing that self-certification did not lead to an increase in absenteeism, and in 1969 GPs even went on a sick note ‘strike’ – a period one doctor described as ‘the happiest in his career’.

While GPs wanted less detailed forms and fewer of them, trade unions and employers’ organisations demanded more information, so that sick notes could be used to track occupational safety and absenteeism. Some Tories thought they merely made it easier to skive. It was true that some workers could save money if they stayed off work after the three-day waiting period. Though their benefits wouldn’t be as high as their wages, they wouldn’t have to pay travel and work expenses, and the benefit wasn’t subject to tax or National Insurance (it wasn’t technically feasible to tax benefits).

There were also fears that the sick note created perverse incentives for GPs, who were paid depending on how many patients they had on their list. Might they be tempted to write more sick notes in order to meet demand from malingerers? William Jowitt, who had been minister for National Insurance during the war, warned that he

did come across cases – not many – where there were two competing doctors, where one was strict with his certification and the other was lax. The people who were on the panel of the strict doctor were inclined to leave that panel and to go on the panel of the lax doctor, not because the lax doctor was a better doctor, but because from the lax doctor they could more easily get certificates.

The sick note was always a compromise between competing imperatives.

The level at which benefits were set was also the result of compromise. Beveridge wanted National Insurance benefits to pay a bare subsistence income; postwar austerity led the Labour government to introduce them at an even lower level. In 1948, the basic National Insurance benefit was 42s a week for a couple, plus 7s 6d for the first child. That this was below subsistence level was demonstrated by the fact that National Assistance – the taxpayer-funded, means-tested benefit intended to be a backstop against destitution – paid most claimants more. The basic National Assistance payment for a couple was slightly lower, at 40s, but there were additional payments of 7s 6d or more (depending on age) for every child, plus, crucially, support with rent. As a result, the National Assistance system didn’t fade away over time, as Beveridge had imagined it would, but grew in significance.

National Assistance – later renamed Supplementary Benefit – still didn’t meet the needs of many sick and disabled people. In the late 1960s, the sociologist Peter Townsend showed that disability and chronic illness were two of the factors most likely to lead to poverty in the UK. The Nelson family, interviewed by Townsend’s team in 1968, was typical. Mr Nelson, 35, had worked as a driver, with a salary well above average, until epilepsy and clots on the brain had forced him out of work six years earlier. He went to the doctor once a month for prescriptions and a sickness certificate. His wife, who had bronchitis and rheumatism, had given up work as an office cleaner to look after him. They and their three sons lived in a four-room council flat in Oldham. They received £10.25 a week in sickness benefit, £1.05 in supplementary benefit, 90p in family allowances and £2.60 for their rent, paid directly by the Supplementary Benefits Commission to the council. One of their bedroom windows had been smashed; since they couldn’t afford to replace the glass, they didn’t use the room. The parents didn’t have a cooked meal on Tuesdays, and often not on Mondays, because their weekly benefit had run out by then. They got a pint of milk each day and watered it down. They had no holidays, and no birthday parties for the children. The boys wore plimsolls to school because they couldn’t afford proper shoes.

In the decade after 1968, the first cash benefits specifically for disabled people were introduced, partly because of the revelations of sociologists like Townsend, and partly because of pressure from the nascent disabled people’s movement, the first intimations of which came in 1965 when two disabled housewives in Godalming formed the Disablement Income Group. Attendance Allowance was created for those who needed round-the-clock support; Invalidity Benefit gave extra money to those claiming sickness benefit over the long term; and Mobility Allowance helped with the cost of getting around. The claims of the long-term sick and disabled had finally been recognised within the social security system, though support was patchy and often inadequate. GPs issued yet more sick notes.

Sickness benefits were significantly reformed by the Thatcher government. In 1982, workers were finally allowed to self-certify for short illnesses – anything up to a week – and in 1983, the responsibility for providing sick pay in short-term cases (up to eight weeks) was transferred from the Department of Health and Social Security to employers. (One effect was that these payments could finally be taxed.) Initially, employers could claim back much of the cost from the state, but over time the refunds diminished to almost nothing.

The abolition of sick notes for short-term illness was the least controversial aspect of the Thatcher reforms – employers were much more concerned about the new Statutory Sick Pay. The old system pooled employers’ risk, but the new system meant that employers, especially those in dangerous industries or with more female, disabled or older workers, faced the possibility of outsized sick pay bills. Remploy, a nationalised company providing sheltered employment, warned that the new system would force it to employ fewer ‘severely disabled’ people unless the government stumped up more cash. Organised labour and the ‘poverty lobby’ feared that employers, when hiring or firing, would discriminate against workers who were more likely to take sick leave. Thatcher, however, insisted that it was the business of employers to police short-term sickness, and it seems that many stepped up.

The Tories turned their attention to long-term sickness and disability benefits. Spending on Invalidity Benefit had grown substantially since its introduction in the 1970s, not least because of deindustrialisation and the Tories’ habit of putting the newly out of work on disability benefit, so they wouldn’t show up in unemployment figures. In the early 1990s, John Major’s secretary of state for social security, Peter Lilley, began to focus on Invalidity Benefit, or, as he called it, ‘bad back benefit’. Announcing his intention to close down ‘the something-for-nothing society’ at the Conservative Party Conference in 1992, Lilley travestied The Mikado: ‘I’ve got a little list/Of benefit offenders who I’ll soon be rooting out/And who never would be missed.’ In 1995, the government introduced Incapacity Benefit, with a new testing regime intended to replace sick notes as the gateway to claims. The All Work Test measured a claimant’s ability to perform tasks like standing, rising from sitting, reaching, speaking and seeing; only if the combined score was high enough would they be found eligible for benefit. The test wasn’t administered by GPs but by medical professionals employed by the Benefits Agency Medical Service; the BMA expressed concern that they might be insufficiently qualified. The All Work Test eventually became the Work Capability Assessment.

Despite, or perhaps because of, the increasingly punitive approach to assessing long-term sickness and disability claimants, the right-wing press became obsessed in the late 1990s with the idea of an epidemic of bogus claims. ‘Sign Up Here for Sick-Note Britain,’ a Daily Mail headline read in 1998; the piece attacked disability benefit claimants as ‘habitual malingerers and spineless quitters’. New Labour enshrined new rights for disabled people in law, ratifying the United Nations Convention on the Rights of Persons with Disabilities in 2009, but, with an eye on the right-wing press, the Blair and Brown governments also emphasised their commitment to getting more disabled people into work. They did nothing to end the testing regime. In fact, they extended its central principle.

In 2010, the Brown government abolished the Med 3 form (the successor to Med 1 and Med 2B), replacing the ‘sick note’ with the ‘fit note’, which is supposed to specify which parts of their job an individual can still do, rather than simply declaring them ‘fit to work’ or ‘sick’. The idea was that this would keep individuals attached to the labour force, rather than funnelling them into long-term benefits. In practice, however, the ‘fit note’ is usually used in the same way as the old sick note – to sign people off, based on ipse dixit. Even if a radical programme like Universal Basic Income were to be implemented, there would almost certainly still be extra payments for chronically ill and disabled people, and sick notes – relatively cheap and bureaucratically straightforward – would probably be pressed into service.

Millward​ wants the sick note to represent the welfare state as a whole: always a compromise but enduring over time although it’s questioned. In the end, though, it’s not a very helpful analogy: the outcomes of most political processes are compromises, and, while the sick note has endured, the British welfare system has been radically – and repeatedly – transformed since the era of Beveridge and Attlee.

The profound changes produced by Thatcherism are well known: a shift away from universalism towards means-testing, the erosion of entitlements, privatisation, and a focus on markets and market-like structures in the name of ‘efficiency’. Other developments are less familiar, such as the challenge mounted by disabled activists from the mid-1960s to the ableist biases in the system. Millward traces these changes, but there are others that the sick note doesn’t shed any light on. Tracking its fortunes gives a frustratingly partial view of the history of the welfare state.

Perhaps the most consequential transformation missed by a concentration of the sick note was the shift towards in-work benefits which began in the early 1970s under Ted Heath, and was driven by deindustrialisation, the decline of the unions from the 1980s, and the consequent growth of inequality and in-work poverty. Critics said that Heath’s Family Income Supplement – which gave a tiny top-up to low-waged families – was a return to the Speenhamland system of the early 19th century, in which the state subsidised starvation wages. In-work poverty, and in-work benefits, have only grown in the decades since (almost two in five Universal Credit claimants are in work).

The analogy between the welfare state and the sick note also ignores the fact that, unlike the sick note, the welfare state has been consistently popular with the public – despite the carping of the Daily Mail. Grassroots critics of welfare have rarely called for cuts but overwhelmingly for expansion: for the system to live up to the high hopes invested in it. It’s true that working-age benefits are probably the least popular part of the system. Nevertheless, even in 1988, at the height of Thatcherism, more people said they wanted a society that ‘emphasises the social and collective provision of welfare’ (55 per cent) than one ‘where the individual is encouraged to look after himself’ (40 per cent). A study this year by Bright Blue, a right-wing think tank, found that 72 per cent of the public feel social security should be ‘meeting the cost of living’, and 77 per cent think those with long-term health problems, and their carers, should be receiving more. In this context, the inadequacy of Statutory Sick Pay and of Universal Credit represents a profound failure of our politics.

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Vol. 45 No. 10 · 18 May 2023

Florence Sutcliffe-Braithwaite’s piece on the sick note took me back to my childhood in the mid-1950s, when my mother worked as a cleaner in a Tyneside doctor’s surgery (LRB, 13 April). I would pass the surgery on my way to school and there was often a queue at the waiting-room door, especially on Mondays when the numbers would be bolstered by coalminers. These celebrants of the Feast of St Monday considered the doctor a ‘canny lad’ because of his willingness to issue sick notes. GPs were permitted to charge for this service; at the surgery where my mother worked the rate was one shilling, which the doctor collected in a tin box. Each Friday my mother, a member of the 1950s precariat, was given an envelope containing her wages, paid entirely in shillings. She never received National Insurance stamps.

GPs were de facto notaries in working-class communities, boosting their income with fees for tasks such as signing passport photos (I recall that the charge for this service many years ago was a fiver). A friend of mine in the early 1980s, starting out on her first not very well-paid job as a junior hospital doctor, was delighted when she had the chance to earn ‘ash money’ – her fee for the additional signature required on a death certificate when the body was to be cremated.

Bill Lancaster
Hutton Rudby, North Yorkshire

Vol. 45 No. 11 · 1 June 2023

Bill Lancaster mentions the ‘ash money’ paid to a friend of his, a junior doctor, in the 1980s (Letters, 18 May). My brother was a junior doctor then too and remembers ‘ash cash’. The fee at that time was £23.50 and wasn’t paid for signing the death certificate, as Lancaster writes, but the cremation form certifying that the body had no implants. Pacemakers were a particular worry, since they could blow up in the incinerator. My brother recalls that a friend of his once overlooked a pacemaker when signing a form, only for it to explode at Reading Crematorium, putting it out of action for a couple of weeks.

Charles Lucas
London W6

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