Rising unemployment and increasing spatial health inequalities in England: further extension of the North-South divide
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Journal of Public Health Advance Access published January 4, 2013 Journal of Public Health | pp. 1–9 | doi:10.1093/pubmed/fds085 Rising unemployment and increasing spatial health inequalities in England: further extension of the North – South divide Holger Möller1,2, Fiona Haigh3, Chris Harwood2, Tony Kinsella2, Daniel Pope4 1 University of Liverpool, School of Management, Liverpool L69 3BX, UK 2 NHS Wirral, Performance and Public Health Intelligence Team, Old Market House, Hamilton Street, Birkenhead CH41 5LF, UK 3 Centre for Health Equity Training Research & Evaluation, University of New South Wales, LMB 7103, Liverpool BC NSW 1871, Australia 4 Department of Public Health and Policy, University of Liverpool, Whelan Building, Quadrangle, Liverpool L69 3GB, UK Address correspondence to Holger Möller, E-mail: firstname.lastname@example.org A B S T R AC T Background Unemployment negatively affects health. In this study, we quantify the impact of current and rising levels of unemployment on limiting long-term illness (LLTI), mental health problems and mortality in North and South England. Methods Excess cases of LLTI and mental health problems in the unemployed were calculated as the difference in the prevalence between the employed and unemployed using data from large population surveys for England. Mortality due to unemployment was calculated using the formula for the population-attributable fraction. Results Current levels of unemployment were estimated to be causing 1145 deaths per year and a total of 221 020 cases of mental health problems and 275 409 cases of LLTI in England. Rates of mortality, mental health problems and LLTI due to unemployment were distinctively higher in the North compared with the South. Considering hidden unemployment in the calculations considerably increased the proportion of women suffering from ill health due to unemployment. Conclusions Our study quantifies the detrimental effect of unemployment on health in England. There is a clear difference between North and South England highlighting the contribution of unemployment to spatial health inequalities. A public health priority should be to (i) prevent unemployment in the first place and (ii) provide support for the unemployed. Keywords economics, education, employment and skills, finance and industry, morbidity and mortality Introduction could be missed by being classiﬁed as economically in- active.2 It was estimated that hidden unemployment was Unemployment has risen steeply in England since the start around 1 million in England in 2007.2 of the ﬁnancial crisis. Approximately 2.2 million people were Despite small improvements in the ﬁrst quarter of 2011, unemployed at the end of 2011, an increase of almost 62% unemployment rates are predicted to further increase due to compared with the last quarter in 2007.1 The true level of slowing economy and large numbers of public sector jobs unemployment is likely to be even higher due to hidden un- employment.2 Measures of unemployment include job seekers allowance (JSA) claimant count and the International Labour Organization (ILO) deﬁned unemployment: ‘per- Holger Möller, Research Fellow centage of unemployed available for work, who have been Fiona Haigh, Research Fellow actively looking for work in the last 4 weeks per economical- Chris Harwood, Intelligence Manager ly active population’.3 Whilst the ILO expands on the JSA Tony Kinsella, Head of Performance and Intelligence claimant count a large proportion of hidden unemployment Daniel Pope, Lecturer in Epidemiology # The Author 2013, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved 1
2 J O U R NA L O F P U B L I C H E A LT H being cut through government austerity measures.4 There is Morbidity a great variation in unemployment by geographical region Unemployment has been linked with LLTI5,6 and mental and by socioeconomic status. Unemployment rates in the health problems29 – 32 and a number of studies have sug- North East (10.4%) are almost double than those of the gested a positive relationship between unemployment and South East (5.9%) and rates in the most deprived (16.7%) heart disease.33 – 36 Whilst there is good evidence for the as- are 4.4 times those in the least deprived (3.9%).1 sociation of unemployment with mental health problems The negative health effects of unemployment have been and LLTI, evidence for the association with heart disease is studied extensively and unemployment has been linked with inconclusive.37 The analysis was therefore restricted to these increased morbidity5 – 7 and mortality.8 Unemployment has outcomes. also been shown to negatively affect the family and wider Calculations for LLTI and mental health problems were community9 – 11 and tends to disproportionately impact on based on two studies of British Household Panel Survey certain vulnerable population groups such as women, young data (Table 1).5,32 The ﬁndings of these studies are in line people, the least educated and lower socio-economic with those of other studies.6,29 and were chosen for calcula- groups.12,13 Differences in regional employment rates have tions of impact as they are reﬂecting British data and differ- been shown to account for health inequalities between entiating by sex. The upper and lower limits of the estimates regions in England.14,15 of effect were explored in a sensitivity analysis (Table 1). In contrast, studies on the effect of economic recession at a population level have reported overall mortality to decrease Mortality or remain unchanged during recession.16 – 22 While this may Longitudinal studies from the 1980 and 1990s have pro- seem paradoxical, such decreases have been explained by a vided strong evidence for a causal relationship between un- corresponding reduction in work- and trafﬁc-related acci- employment and increased mortality.34,38 – 42 A recent dents16,17,22 – 24 and people adopting healthier life styles out meta-analysis of 42 studies reported signiﬁcant pooled esti- of necessity due to ﬁnancial constraints.22,25,26 Rather than mates of effect of 1.78 and 1.37 for all-cause mortality in study the population as a whole the current research focuses unemployed men and women, respectively.8 on the health effects on the unemployed. While some of the associations observed in earlier studies This study estimates the impact on mental health pro- may have been inﬂuenced by confounding of individual risk blems and limiting long-terms illness (LLTI) and mortality factors, a Swedish study, which controlled for pre-existing in England of current unemployment and a rise in rates of health conditions and a large number of confounders, unemployment. To investigate the regional differences reported statistically signiﬁcant positive associations between England is divided into North and South using the geo- unemployment and mortality outcomes.43 Alternative graphical boundaries adopted in a recently published study methods of adjusting for confounding has been to study the summarizing differential mortality between North and health effects of unemployment in times of generally high South England.27 unemployment, therefore reducing possible bias of health selection44, and to exclude deaths occurring in the ﬁrst few years after unemployment from the analysis, as these are more likely to be due to pre-existing health problems.45,46 Methods Most studies on mortality compared the unemployed with Excess cases of mental health problems, LLTI and mortality the employed, hence not being directly transferable at the in the unemployed were calculated based on the best avail- population level as they are missing out the economically in- able evidence from large population studies and routine data active group. Based on an analysis of a large population for North and South England. For unemployment the def- sample from census data for Finland, Martikainnen and inition of the ILO3 was used. Unemployed not meeting Valkonen reported 3.1- and 2.4-fold increased risk of mor- these criteria were classiﬁed as economically inactive. Of the tality in inactive men and women, respectively.47 inactive, those who would like a job and are able to start The effect of unemployment on all-cause mortality was within the next 2 weeks were included in the analysis to con- estimated using the age stratiﬁed results of the meta-analysis sider hidden unemployment. Excess morbidity was calcu- by Roelfs et al.8 for statistical modelling (Table 1). In a sensi- lated as the difference in the prevalence between tivity analysis, the impact of applying the ﬁndings of a sub- unemployed and employed and mortality by using the analysis by Roelf et al.8 and those of the studies by Lundin formula for the population-attributable fraction (PAF).28 et al.43 and Martikainnen et al.44 were explored (Table 1).
U N E M P LOYM EN T A N D H E A LT H I N EQUA L I TI ES 3 Table 1 Estimates of effect taken from the literature for LLTI, mental health problems and mortality used in the main model and sensitivity analysis Outcome Age Men Women Based on the study Main model Mental Health problems All age groups 2.05 1.72 Thomas et al.32 LLTI All age groups 2.41 2.06 Bartley et al.6 Mortality 16– 39 1.73 1.73 Roelfs et al.8 40– 49 1.77 1.77 Roelfs et al. 8 50– 64 1.25 1.25 Roelfs et al. 8 Sensitivity analysis Mental health problems All ages 1.71 1.39 Lower 95% CI, Thomas et al. 32 All ages 2.47 2.12 Upper 95% CI, Thomas et al. 32 LLTI All ages 1.92 1.68 Lower 95% CI, Bartley et al. 6 All ages 3.01 3.12 Upper 95% CI, Bartley et al. 6 Mortality All ages 1.56 1.17 Lower 95% CI, Roelfs et al. 8 All ages 2.02 1.60 Upper 95% CI, Roelfs et al. 8 All ages 1.30 1.30 Lundin et al. 43 All ages 1.25 1.25 Martikainnen et al. 44 a 16– 39 1.95 1.73 Roelfs et al., sub-model8, 8,a 40– 49 1.86 1.34 Roelfs et al., sub-model a 50– 64 1.17 0.94 Roelfs et al., sub-model8, a Based on 93 hazard ratios which were adjusted for age, had an age range smaller or equal to 35 years, did not use the general population as the control group and did not include persons not in the labour force in the case group and were from studies with less than a 1 year gap between the end of baseline and the beginning of follow-up. Table 2 Overview of surveys and measures used in the analysis Survey Sample Measures used in the study Labour Force Survey48 n ¼ 57 747 (48.5% men, 51.5% Number of unemployed and inactive wanting a job and able to start work women) within 2 weeks Health Survey for n ¼ 3594 (45.7% men, 54.3% women) Prevalence of LLTI in employed. LLTI was measured in questionnaire as: ‘presence England 200949 of these 2787 were employed of longstanding illness that is limiting activity’. Adult Psychiatric n ¼ 5425 (43.6% men, 56.4 women) Prevalence of mental disorders in employed. In the survey mental health Morbidity Survey 200750 of these 3964 were employed problems were measured using the revised Clinical Interview Schedule (CIS-R). A score of .12 indicates the presence of significant neurotic symptoms and people with a score of 18 or above are likely to require clinical treatment Data sources as weighted proportions using individual weights supplied in Mortality data for England for 2009 were obtained from the the respective data sets. Ofﬁce for National Statistics. Unemployment data were extracted from the quarter four 2010 Labour Force Survey (LFS).48 The prevalence of LLTI and mental health pro- Statistical analysis blems in the employed was calculated from the Health The effects of current levels and a 1% increase in un- Survey for England (HSE) 2009 49 and the Adult employment on morbidity and mortality were calculated for Psychiatric Morbidity Survey (APMS) 200750, respectively the age groups 16 –39, 40 – 49 and 50– 64. Calculations (Table 2). The prevalence rates for LLTI and mental health were carried out using Stata version 1051 and Microsoft problems by employment status and region were calculated Excel. England was split into North and South for the
4 J O U R NA L O F P U B L I C H E A LT H analysis by government ofﬁce regions using the same divid- the North and 356 100 (54%) in the South (Supplementary ing line between the Wash and Severn Estuary as a recent data, Table S2).52 publication by Hacking et al.27 Excess cases of LLTI and mental health problems among Prevalence of LLTI and mental health problems the unemployed (Nex) were calculated as Based on the ﬁndings of the HSE 2009 for assessment of Nex ¼ ðPe RRu Nu Þ ðPe Nu Þ ð1Þ LLTI and the AMPS for mental health problems, 12.2% of 16– 64 year olds employed were suffering from LLTI and where Pe is the percentage of people with LLTI or mental 12.9% from mental health problems in England. Rates of health problems in the reference population (employed), mental health problems in women were signiﬁcantly higher RRu the increased risk in the unemployed and Nu the in the North compared with the South (Supplementary data, number of unemployed. Table S3). The three leading causes of LLTI in 16 –64 year Mortality in the 16– 64 olds economically active was cal- olds were problems of the musculoskeletal system (27.9%), culated by subtracting mortality in the economically inactive mental disorders (11.9%) and problems of the heart and cir- from the total mortality in that age group using the ﬁndings culatory system (11.5%). by Martikainnen et al.41 Mortality in the inactive and unemployed was calculated using the formula for the PAF:25 Morbidity attributable to unemployment PðRR 1Þ Current levels of unemployment were estimated to contrib- PAF ¼ ð2Þ ute to 221 020 cases of mental health problems and 275 409 PðRR 1Þ þ 1 cases of LLTI in England (Table 3). Men represent 51.2% where P is the prevalence of economic inactivity or un- of those individuals with mental health problems and 62.8% employment and RR the relative risk of mortality. of LLTI. A 1% increase in unemployment was estimated to The expected excess mortality due to increased un- result in an additional 35 624 cases of mental health pro- employment was calculated using the formula: blems and 52 571 cases of LLTI (Table 4). Rates were sig- Ðm Ðm niﬁcantly higher in men and women in the North compared RRðxÞPðxÞdx x¼0 RRðxÞP 0 ðxÞdx with the South (Tables 3 and 4). The 16– 39 year olds con- PAF x¼0 Ðm ð3Þ x¼0 RRðxÞPðxÞdx tributed the largest amount of mental health problems (52.3%) and LLTI (69.6%) (Fig. 1) and the 40 –49 and where P(x) is the proportion of population at each exposure 50– 64 year olds had the highest rates measured per un- level, RR(x) the relative risk of mortality for each exposure employed population (Supplementary data, Fig. SA1). category level, P 0 (x) the counterfactual proportion of popula- Including hidden unemployment in the analysis was esti- tion at each exposure level and m the maximum exposure mated to result in a 74% increase in mental health problems level. Increased levels of unemployment were deﬁned as a and a 66% increase in LLTI. The percentage contribution of counterfactual scenario.28 women also increased, reﬂecting the high prevalence of in- active women who would like to work (Table 3). Sensitivity analysis calculated the estimates for England for current Results levels of unemployment of between 134 929 and 326 220 Unemployment in England for mental health problems and between 178 577 and 451 According to the 2010 LFS,48 1 036 456 people (59% men, 391 for LLTI (Supplementary data, Tables S4 and S5). 41% women) were unemployed in the North and 985 463 (57% men, 43% women) in the South of England. Mortality attributable to unemployment Unemployment rates were highest in the 16 –39 year olds, Around 1145 deaths (628 in the North and 517 in the higher in men compared with women and higher in the South) in the 16– 64 year olds were estimated to be attribut- North compared with the South for the 16 – 39 and 40 –49 able to current levels of unemployment in England per year. year olds. Of those who are economically inactive and able Rates were higher in the North compared with the South to start work, 675 162 (57% women, 43% men) wanted a (Table 3). About 72% of deaths related to men with the job; the majority of whom were aged 16 – 39 (52%) largest proportion of deaths occurring in the 16– 39 and (Supplementary data, Table S1). From 2007/08 to 2011/12 40– 49 year olds (36%) (Fig. 1). The older age groups had the number of unemployed had risen by 419 100 (60.2%) in the highest attributable mortality rates (Supplementary data,
U N E M P LOYM EN T A N D H E A LT H I N EQUA L I TI ES 5 Fig. SA1). A 1% increase in unemployment was estimated 105.7, 107.7 228.7, 231.6 108.8, 110.8 222.4, 225.3 Table 3 Mortality, mental health problems and LLTI due to current levels of unemployment (rates per 1000 for LLTI and mental health problems and per 100 000 for mortality and 95% confidence to result in an extra 221 deaths per year (114 in the North 29.5, 40.7 48.4, 62.5 95%CI and 107 in the South) (Table 4). Adjusting for hidden un- employment resulted in an increase of 37% in mortality (Table 3). Sensitivity analysis showed a spread in results 106.7 230.1 109.8 223.9 from 606 to 1773 in the unemployed and from 785 to 2487 35.1 55.4 Rate when adjusting for hidden unemployment (Supplementary data, Tables S4 and S5). Number Women 45 789 98 740 47 127 96 048 150 238 Discussion 140.6, 142.5 133.7, 135.6 212.6, 215.0 93.0, 94.6 59.1, 72.6 81.3, 97.0 Main findings 95% CI Current levels of unemployment were estimated to be causing around 1145 excess deaths per year, and a total of 141.5 134.6 213.8 221 020 cases of mental health problems and 275 409 cases 93.8 65.9 89.2 Rate of LLTI in England. A 1% increase in the unemployment rate was calculated to result in an extra 221 death per year, 118 945 Number 52 198 78 759 74 912 35 624 cases of mental health problems and 52 571 cases of South Men 367 496 LLTI. Morbidity and mortality rates were distinctively higher in the North compared with the South, indicating that dif- 145.2, 147.5 281.4, 284.6 128.9, 131.1 241.3, 244.3 ferential unemployment rates exacerbate geographical health 33.8, 45.8 52.6, 67.4 95% CI inequalities. Considering hidden unemployment suggests that women might be suffering to a much greater extent from unemployment, than reﬂected in routine statistics. This 146.4 283.0 130.0 242.8 supports the argument by Bambra that the current econom- 39.8 60.0 Rate ic crisis is likely to have a much greater effect of women than any of the past recessions.13 120 209 103 119 Number Women 62 163 55 205 Sensitivity analysis indicated the possible range of out- 169 255 comes and, even for the most conservative assumptions, the numbers of cases of mental health problems, LLTI and 142.5, 144.4 159.5, 161.5 228.2, 230.6 98.7, 100.3 86.9, 102.3 mortality due to unemployment were still of signiﬁcant 68.1, 81.8 95% CI magnitude. What is already known on the topic 143.5 160.5 229.4 99.5 75.0 94.6 Rate Unemployment has been linked with increased morbidity5 – 7 and mortality.8 Studies on economic cycle and health 140 347 Number 60 870 87 762 98 165 reported increases in suicide and decreases in mortality from North Men 459 579 trafﬁc accidents during times of recession.16,17,22 While some studies reported a decrease in overall mortality during Unemployed þ inactive wanting job Unemployed þ inactive wanting job Unemployed þ inactive wanting job economic downturn17,20 – 22,53 others have found no change in all-cause mortality.16,23 A recent study reported an in- crease in suicides during the 2008 – 10 economic recession in England and showed a strong correlation with local un- employment rates.53 The differences in mortality found between North and Unemployed Unemployed Unemployed Mental illness South England are in line with the ﬁndings reported by Hacking et al. 27 suggesting that the differential unemploy- Mortality intervals) ment could be a contributory factor to these higher mortal- LLTI ity rates.
6 J O U R NA L O F P U B L I C H E A LT H Table 4 Mortality, mental health problems and LLTI per 1% increase in unemployment (rates per 1000 for LLTI and mental health problems and per 100 000 for mortality and 95% confidence intervals) North South Men Women Men Women Number Rate 95% CI Number Rate 95% CI Number Rate 95% CI Number Rate 95%CI Mental illness 9436 15.4 15.1, 15.7 9018 21.2 20.8, 21.7 8958 16.1 15.8, 16.4 8212 19.1 18.7, 19.6 LLTI 18 338 30.0 29.5, 30.4 9186 21.6 21.2, 22.1 15 898 28.6 28.1, 29.0 9150 21.3 20.9, 25.7 Mortality 72 11.7 9.0, 14.4 42 9.9 6.9, 12.9 68 12.2 9.3, 15.1 39 9.0 6.2, 12.9 Mental health problems risk of LLTI in the economically inactive. We limited the 80 LLTI analysis to the 675 162 inactive, wanting a job, who are able 70 Mortality to start work. These are likely to be conservative estimates, 60 considering that 1.7 million of the economically inactive 50 wanted a job1 and Beatty et al.2 estimated around 1 million Percent 40 people to be suffering from hidden unemployment in 30 England in 2007. 20 10 Health selection is a known problem in the study of un- 0 employment and it has been postulated that the strength of 16–39 40–49 50–64 16–39 40–49 50–64 the relationship between unemployment and poor health Male Male Male Female Female Female decreases during periods of recession as more people are Fig. 1 Percentage distribution of mental health problems, LLTI and drawn into the unemployed category.14 This is supported by mortality due to unemployment by age groups and sex in England. the studies of Martikainnen et al. and Lundin et al., which reported lower increased risk of mortality in times of eco- What this study adds nomic recession and after adjusting for pre-existing health This study is the ﬁrst to estimate the impact of unemploy- conditions, respectively.43,44 Both these studies were ment on morbidity and mortality in the unemployed popula- included in the sensitivity analysis of our study. Another ap- tion in England. Estimates of population-level health proach to adjust for health selection has been to exclude impacts provide valuable evidence to support policy-makers deaths occurring in the ﬁrst few years after unemployment and commissioners of health services for decision-making from the analysis.45,46 A recent UK study found no differ- and planning processes. Identifying regional differences ence in mortality with or without using a wear-off period in highlights potential impacts of the recession on geographical the analysis and concluded that there was little evidence of a health inequalities. This study focused on the unemployed selection effect operating on the unemployed in their and also considered hidden unemployment; these groups study.46 Similarly Akinwale et al.54 reported the pattern of have not been speciﬁcally considered in previous population mortality by labour market position to be unchanged after level studies on unemployment and health. In addition our applying a wear off period of 5 years. study also estimates morbidity outcomes and uses current Mortality in the unemployed was calculated by subtracting exposure data to provide up to date estimates of the current mortality in the inactive from the total mortality. To calculate recession. mortality in the inactive we used risk estimates from a large Finnish population study.47 These estimates are higher com- Limitations pared with those of a recent UK study,54 indicating that esti- The analysis was extended to include the inactive wanting a mates for the unemployed may be conservative. However, job and able to start work in the next 2 weeks to adjust for Aikinwale et al.54, only looked at the older age groups and it hidden unemployment. Only limited studies have looked at is not clear if the difference would remain for all age the inactive separately. The economically inactive have been groups. shown to experience higher mortality compared with the The prevalence of mental health problems among the economically active8,47,54 and Bartley et al. 6 reported higher employed differed between North and South regions of
U N E M P LOYM EN T A N D H E A LT H I N EQUA L I TI ES 7 England and to estimate the relationship in the unemployed Acknowledgements we applied national values. The true increase in mental This work contains data from the Health Survey for health problems and LLTI in the unemployed might also England and Adult Psychiatric Morbidity survey from the differ by region, which could not be adjusted for in this National Centre for Social Research. These studies were study. Other health problems might be related to unemploy- commissioned by the Information Centre for Health and ment that were not included in this study, indicating that the Social Care and the data are available through the UK data true impact might be even greater. archive. Data for the Labour for Survey is from Ofﬁce for Due to small sample size at a regional level of the HSE National Statistics, Social Survey Division, also available and APMS surveys, analysis was limited to North and South through the UK data archive. The data are Crown copyright of England. There are potentially large inter regional inequal- material is reproduced with the permission of the Controller ities15 which could not be considered in the analysis. Further of HMSO and the Queen’s Printer for Scotland. The origin- regional breakdown should be included in future analysis. al data creators, depositors or copyright holders, the funders The calculation of mortality attributable to unemployment of the Data Collections (if different) and the UK Data was based on the methodology of the PAF.28 By necessity this Archive bear no responsibility for their further analysis or method uses relative risks from the best available evidence interpretation of the data. We thank Sacha Wyke from base from literature reviews. This method may yield biased North West Public Health Observatory for providing the estimates when used with relative risk estimates adjusted for mortality data extract and Liz Harris and Scott Walter from confounding.55 This potential bias has been explored and University of New South Wales and Louisa Jorm from Darrow and Steenland56 reported that when the crude relative University of Western Sydney for commenting on the paper. risk is greater than the adjusted, as would be the case in our study, the attributable fraction may be underestimated. Funding Conclusion Our study clearly demonstrates the detrimental effect of un- This project was funded by Wirral Primary Care Trust. employment on health in England. Women might be suffer- ing to a much greater extent from unemployment, than References reﬂected in routine statistics. There is a clear difference between North and South England highlighting the contribu- 1 Ofﬁce for National Statistics (ONS). Nomis ofﬁcial labour market statistics, annual population survey, 2011. http://www.nomisweb.co. tion of unemployment to health inequalities. This is sup- uk/articles/554.aspx (11 January 2012, date last accessed). ported by the fact that the gap in unemployment between the 2 Beatty C, Fothergill S, Gore T et al The real level of unemployment most and least deprived groups of the population has 2007. Shefﬁeld: Centre for Regional Economic and Social Research increased since the start of the ﬁnancial crisis. While the (CRESR), 2007. http://www.shu.ac.uk/_assets/pdf/cresr-RealLevel overall impact of the economic crisis might not change the Unemployment07.pdf (12 April 2012, date last accessed). heath status at a population level or even have beneﬁcial 3 Hussmanns R. Measurement of employment, unemployment and effects as highlighted earlier,17,20 – 22 the detrimental health underemployment—current international standards and issues in consequences of unemployment cannot be overlooked. The their application. Geneva: International Labour Organisation, 2007. http://www.ilo.org/wcmsp5/groups/public/– -dgreports/– -stat/ results of our study show that everything possible should be documents/publication/wcms_088394.pdf (12 April 2012, date last done to avoid unemployment in the ﬁrst place and support accessed). the unemployed as much as possible. Social protection has 4 The Chartered Institute of Personnel and Development (CIPD). been shown to mitigate the negative health effects of un- UK jobs market takes a turn for the worse: looks like the only way employment16 and Bambra highlighted the different levels of is up for unemployment.http://www.cipd.co.uk/pressofﬁce/press- intervention at the macro, meso and the individual level.57 releases/uk-jobs-market-takes-turn-for.aspx (11 January 2012, date Special focus should be paid to the most vulnerable groups last accessed). such as lower qualiﬁed workers and young people which have 5 Bartley M, Plewis I. 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