- Observatory: EurWORK
- Labour market policies,
- Health and well-being at work,
- Working conditions,
- Published on: 20 november 2014
Disclaimer: This information is made available as a service to the public but has not been edited by the European Foundation for the Improvement of Living and Working Conditions. The content is the responsibility of the authors.
Chronic diseases impact about 20% of the population but there is a lack of data and surveys about the employment of people with chronic diseases. Even if the public agency ANACT is very active in this field, employees with chronic disease are still a category of employees which has to face an increasing risk of unemployment, precarious professional career and discrimination.
Block 1: Concept, definitions, sources of information and methodological issues on chronic diseases and work from the national perspective
1.1. National definition of chronic disease
There is no specific national definition in France of chronic disease in an employment context. The definition commonly used is the general definition of chronic disease. This definition is rather similar to the one provided by the World Health Organisation. The definition can be found in the 2007-2011 Plan for the improvement of the quality of life of people with chronic diseases, issued by the French Ministry of Health. A chronic disease is “a long-term illness, progressive, often linked to a disability and to the threat of serious complications”. Chronic diseases include:
- illnesses such as chronic renal failure, chronic bronchitis, asthma, cardiovascular disease, cancer, diabetes, highly handicapping diseases such as multiple sclerosis
- rare diseases such as cystic fibrosis, sickle cell disease and myopathies
- on-going communicable diseases such as AIDS or hepatitis C
- long-term mental disorders such as depression or schizophrenia
The list of 30 chronic diseases that allow for the people to be reimbursed at 100% of their health expenses by the National health insurance (Assurance maladie) figures in the article D-322-1 of the Social security code. The government may change this list with a decree as it has done recently with the decree n° 2122-726 of the 24 June 2011 that excluded severe arterial hypertension from the list.
1.2. Information on national sources of statistical information dealing with the issue of chronic diseases and their relation to employment and working conditions
In France, the main body dealing with information relating to chronic diseases and their relations to employment and working conditions is the ANACT (Agence Nationale pour l'Amélioration des Conditions de Travail – National Agency for the Improvement of Working Conditions). This agency works under the authority of the Ministry of Labour and is divided in 26 regional agencies (ARACT).
Based on the national definition, the regional agency of Aquitaine has taken the lead in the field of chronic diseases and employment. A guide has been published in 2008 about progressive chronic diseases and a specific website is available online (http://www.maladie-chronique-travail.eu/). The focus is mostly placed on how to maintain workers with chronic diseases in employment and consequently, how to improve their working conditions.
The ANACT is also providing training in this field to raise awareness on this issue for stakeholders such as companies or social partners.
The ANACT is the main actor providing information and statistics on chronic diseases to other actors, such as patients' associations and has contributed to the PH-Work project (Promoting Healthy Work for People with Chronic Illness) which resulted in the publication of a European good practice guidance -
Block 2: Prevalence, recent evolution and effects of the problem of chronic diseases among workers and companies
2.1. People affected by chronic diseases and employment
In the 2007-2011 Plan for the improvement of the quality of life of people with chronic diseases, it was estimated that about 15 million people were affected by one or more chronic diseases, about 20% of the French population. But there is no specific statistical system to identify the exact number of people with chronic diseases. The most relevant data is the number of people that needs a long-term and costly medical treatment. This category represented about 7.5 million of the people covered by the general regime of the National health insurance (Assurance maladie) in 2006 when the Plan was launched. The National health insurance called this category “chronic long-term illness” (“affection de longue durée” – ALD). People covered by the ALD scheme see all their health expenses reimbursed at 100% by the National health insurance.
The plan forecasts that the number of people in ALD scheme would reach 10 million by 2010. However the last data published on the 31 December 2012 are lower than expected. A total of 9,459,664 people were considered with one or more of the 30 chronic diseases (in comparison to 8 million by 31 December 2007). 51.8% were women and 48.2% men. Their average age is 62 years old (61.6 years by the end of 2007), with large differences between the type of sickness: from 21 years (cystic fibrosis) or 25 years (Structural scoliosis) to 76 years (Alzheimer). Some others hit in particular the workforce as HIV (45 years). The main chronic diseases are diabetes (2,124,682 million of people), cancer (1,988,252), long-term psychiatrics conditions (1,155,525), severe high blood pressure (1,135,738) and heart disease (1,008,198). According to a survey launched in 2007, there is a continuous increase in chronic diseases: + 5.7% each year between 1994 and 2004, + 3.6% between 2006 and 2007, + 4.2% between 2006 and 2007 (M. Païta, A. Weill, Points de repère, novembre 2008, n° 20, CNAMTS).
- What is the employment situation of people with chronic diseases in your country (% of people in employment/unemployment/inactivity that are affected by chronic diseases)?
No general data. According to a national survey published in 2013 on people affected by the HIV (enquête VESPA ANRS EN12), the employment rate of people aged under 60 years old reach 57% ; 25% were non-active (early retirement, invalidity...) and the unemployment rate, 18% (Rapport 2010 “Prise en charge médicale des personnes infectées par le VIH”; chapitre 3 Epidémiologie de l’infestion par le VIH, La Documentation française, ministère de la Santé et des Sports). Employees with HIV have five times more risk to be unemployed than the average in the whole population.
- What are the typical employment trajectories of workers affected by chronic diseases? (entry/exit patterns)
It seems that workers affected by chronic diseases have more professional career interruptions and are more prone to be victims of discrimination. This is very clear for employees with HIV (Lhuilier Dominique et al., « Vivre et travailler avec une maladie chronique (vih-vhc) », Nouvelle revue de psychosociologie 2/ 2007 (n° 4), p. 123-141).
- What are the main difficulties/problems for people with chronic diseases to access or stay in the labour market?
According an action research (Anne-Marie WASER (Université de Rouen, CEE), Dominique LHUILIER, Joëlle MEZZA et Kathy HERMAND (CNAM, CRTD), « Quel travail avec une maladie chronique ? Retour sur une recherche-action » Lhuilier Dominique et al., « Vivre et travailler avec une maladie chronique (vih-vhc) », Nouvelle revue de psychosociologie 2/ 2007 (n° 4), p. 123-141) employees with chronic diseases develop a different relationship with work and gain experience that can be a resource for companies. Employers treat these employees as medico-administrative categories and as a result, are invariably perceived negatively due to their low productivity levels or absences from work. They have a negative image related to the medical conception of disease: injury or deficiency creates the disability. The survey also found that they are more often opposed to the following issues, than healthy employees:
- to work intensity by negotiating adapted rhythms and sustainable intensity on account of the illness. Negotiations aimed at obtaining the same treatment as other employees.
- to work that is not (or no longer) meaningful. Illness makes people realise how precious life is and they are consequently more demanding when it comes to committing themselves to a job
- to the lack of consideration from others, notably illness-related ‘otherness’ that increases the risk of being downgraded, or a target for suspicion, discrimination and exclusion
- to the lack of consideration for the general interest or public goods over the long-term (company managements’ short- term economic orientations, productivity, ideological orientations contrary to one’s personal values, pollution with strong ecological impacts, etc.).
- What are the main difficulties/problems for enterprises with workers affected by chronic diseases? What solutions do enterprises adopt to deal with these workers affected by chronic diseases?
Mainly a risk of disorganisation related to absenteeism with a transfer of work to other colleagues. The employer has to find a tailored-made solution for each case of employees with chronic disease which is time consuming, costly – if he has to adapt the workstation or to recruit – and negatively impacts its competitiveness. To help them to manage employees with chronic diseases, ANACT has published guidelines in 2012 (“Promouvoir la qualité de vie au travail des personnes atteintes de maladies chroniques : un guide de bonnes pratiques”, ANACT and European Network for Workplace Health Promotion - ENWHP).
2.2. Working conditions of employed people affected by chronic diseases
There is a lack of data on the relationship between occupations and chronic diseases: important data exist about working conditions – the working conditions surveys (enquête conditions de travail) and the SUMER survey – and the health of the French population (enquête décénnales Santé, enquête HID), but cross survey on both issues, health and health at work didn’t exist before the survey (Enquête Santé et itinéraire professionnel 2007) launched from 2006 to 2010 by the Ministry of Labour (DARES) and the ministry of Social Affairs (DREES). Employees that are 50 years old and are exposed to physical strain (night shift, repetitive work, exposed to chemical products...) have a less good health thanemployees with the same age that are not exposed to such physical strain: 23% of them explain there are limited in their daily life on the ground of health problems against 14% of the 50 years old employees that are not exposed. They are also less in employment that the second group (DREES, “L’état de santé de la population en France. Rapport de suivi des objectifs de la loi de santé publique 2011”, Etude et résultats n° 805, June 2012). The survey highlights several links between health (not only chronic diseases) and type of professional career, period of unemployment or professional mobility (DREES, DARES, “Parcours professionels et état de santé”, Dossier solidarité santé, n° 14, 2010)
- Reconciliation of working and non-working life: are people with chronic diseases allowed special conditions in terms of work-life balance, flexibility at work to cope with the diseases/attend treatment, ability to set their own working time arrangements, etc.?
According to the Labour code, people with serious illness are entitled to different measures to protect their employment and work-life balance. The illness has to figure on the list of chronic disease (Social Security Code, art. 322-1) or to be recognised by the Social security as a serious illness. In that case, each employee has the right to an absence authorisation application to obtain medical treatment (Labour code, art. 1226-5). After his employment contract was suspended formedical reasons, the employee has to visit the occupational doctor. If the doctor estimates he isn’t able to return on work at his former position, the employer is committed to offer a new position in accordance with his capacities and the medical recommendations. If necessary, the employer has to transfer the employee in another unit, to change the workstation or to change the working time organisation. Also, after a sick leave the Labour code provides to employees the possibility to return to their previous position in the framework of a part-time on health grounds (“mi-temps thérapeutique). This part-time has to be agreed by a doctor. The organisation has to be negotiated between the employee and the employer. The employer pays the worked hours and the Social security will take in charge the non-worked hours with health allowance.
- Career and employment security: to which extent and how is the employment status of people with chronic diseases affected by their health situation?; is there an impact in their remuneration levels/conditions?; in what measure is there a repercussion on their employment security and working career?; are they allowed/forced to changes in their jobs?
Sick employees are protected against dismissal. Of course employers can’t dismiss employees on health grounds (Labour code, art. L.1132-1). However, frequent absences or long-term illness may disrupt the smooth operation of the company and allow employers to dismiss an employee with chronic disease. Also, the medical opinion of physical unfitness issued by a doctor can lead to the dismissal in the framework of a specific dismissal process (Labour code, art. 1226-2 to 1226-4-3). In practice, lawyers consider that it is very difficult to dismiss an employee with chronic disease.
When they are on sick leave, employees receive a daily allowance from the Social security (Social security code, art. L. 321-1, 5°) often completed by private insurances (in general in the framework of a collective insurance paid by employers and employees – “régime de prévoyance” or “mutuelle”). For their health expenses, people have all their health expenses reimbursed at 100% by the National health insurance.
According to a study (Situations à l'égard du travail des personnes atteintes de maladies chroniques, Revue d'Épidémiologie et de Santé Publique, Volume 55, Issue 4, August 2007, Pages 253-263, B. Saliba, A. Paraponaris, B. Ventelou), based on the data of 35073 individuals interviewed in the 2002-2003 French Decennial Health Survey, participation in labour market appears, all other things being equal, to be less important for people with chronic diseases. Chronic diseases are more deleterious for blue collar than for white collar workers. The probability to have a part-time job is raised by 60% for people with chronic diseases (100% for men, 50% for women). Suffering from chronic diseases raises the probability to have a desired part-time job rather than a full-time job by 80% (170% for men, 60% for women) and the probability to have an undesired part-time job rather than a full-time job by 50% (30% for men, 50% for women). For the elderly (50-65 years), chronic diseases multiply by three the probability to be out-of-work (and not retired), by two the probability to be retired and by 1.5 the probability to be unemployed compared to being employed. The consequences of chronic diseases on the workplace are not negligible, creating new social inequalities that the French social protection system does not seem to be able to completely cover. Even if the French social protection system establishes a specific regime for people affected by chronic diseases, by which they are completely reimbursed for any health expenses, this regime does not really contribute to improve the stigmatisation of this category of worker in the labour market.
Block 3: Policies and measures adopted by public and private agents to favour the employment situation and working conditions of people with chronic diseases
3.1. Description of main policy measures/initiatives developed by public authorities or social partners
One of the most recent policy measure developed by public authorities in the field of chronic diseases and employment is the 2014-2019 Cancer Plan launched on 4th February 2014.
Each year in France, around 350.000 persons develop cancer, of which 100.000 are workers.
The ANACT is playing an important role in the conduct of this plan focusing on four main priorities:
- curing more patients
- preserving the continuity and the quality of life
- investing in prevention and research
- optimising management and organisation
Regarding employment, the objectives are twofold : the ANACT has been assigned the mission of encouraging both job retention and professional reintegration for workers with chronic diseases.
This plan seems to be essential for the improvement of the quality of life for people with chronic diseases, as it is the third time such a plan has been renewed.
In the 2009-2013 plan, some measures were already taken to facilitate working situations. An overview of the situation has been drawn about the existing mechanisms available to support job retention and re-employment in order to apply and adapt them to workers with chronic diseases. This initiative was financed by the private Foundation ARC promoting cancer research and the INCa (National Institute on Cancer) created by the 2003-2007 plan and placed under the authority of the Ministry of Health.
On the issue of chronic diseases and employment opportunities, the 2014-2019 sets out four measures to continue the efforts already achieved:
- to improve available solutions adapted to the personal situation of people with chronic diseases
- to raise awareness among companies about the twofold objectives
- to move towards a better territorial coordination from the different stakeholders acting on job access or maintenance
- to make known the efforts already made in order to encourage further developments.
3.2. Examples of enterprises and/or collective agreements implementing initiatives or establishing clauses to support people with chronic diseases
The company Delpeyrat in France employs 1,400 workers on 17 different undertakings in the field of catering activities. Two production facilities in Agen and Saint Sever, employing 850 workers, were recently chosen to implement initiatives to support people with chronic diseases.
Actions taken under this program responded to the objective of maintaining workers with chronic diseases within the company.
Five objectives were set :
- Moving from an individual management of job retention for workers with chronic diseases towards a collective management
- Contributing to the improvement of working conditions for all workers
- Maintaining professional skills within the company
- Reducing absenteeism
- Influencing on prevention in link with job retention efforts
The group targeted is very broad as it includes all employees, the management and HR team, the CHSCT (safety and working conditions committee – comité d'hygiène, de sécurité et des conditions de travail) and the health at work team.
Different actions were taken, such as:
- Appointment of a team with a project manager
- Inventory of arrangements already in place
- Identification of the number of reported cases of workers with chronic diseases
- Developing a monitoring and supportive approach by, for instance, implementing dedicated referent on each working site
- Developing communication through the creation of videos and interactive terminals
This initiative, specific to chronic diseases, is conducted in the form of projects aiming at coordinating internal actors within the company. It is adapted to the concrete working situations in the company, and not based on the general pathologies workers might be subjected to.
As a result from the actions taken, it appeared that the management team gained awareness of the consequences progressive chronic diseases and their associated treatment may have on the situation of workers; that the social dialogue was improved thanks to better communication; that arrangements (physical or organisational) were put in place, mainly by resorting to ergonomists; that workers feel less isolated and dare to talk more easily about their issues and that 5 out of 11 dismissals for inability were avoided in the course of 2013 thanks to anticipation of medical contraindications.
There is some concern about the issue of people affected by chronic diseases in an employment relationship. When trying to deal with this issue, measures are often adopted in the framework of more general provisions aiming at improving the quality of life of people suffering from chronic diseases.
More specific measures and surveys are also undertaken, according to the types of disease (Cancer, HIV, etc). Also, measures are taken at different levels: the administration is obviously in charge of tackling this issue, but companies are also taking steps to improve the situation of their employees.
However, efforts are yet to be made as people with chronic diseases are still experiencing important difficulties when it comes to employment relationships. Awareness should be raised among the general population about this issue, as it often appears that the impact chronic diseases can have on the entire working staff is poorly known. Absenteeism results in unexpected changes in work organisation and planning and in distribution of working loads. Because of this lack of knowledge, people suffering from chronic diseases frequently tend to hide their condition in the employment context as they feel stigmatised.