Evidence base special report: NICE guidelines – all things nice

The latest NICE workplace guidance, on mental health at work, was published in November. This is the fourth set of guidance aimed at protecting the health of workers, following guidelines on smoking cessation, physical activity and long-term sickness absence.

The 2005 Labour Force Survey found that about half a million UK workers believed they suffered from stress, depression or anxiety and almost 13 million working days were lost (equivalent to an annual loss of 0.55 days per worker). Mental health problems are the second most commonly reported cause of sickness absence after musculoskeletal disorders.

According to the Foresight Mental Capital and Wellbeing Project (2008), ‘Mental wellbeing is a dynamic state in which the individual is able to develop their potential, work productively and creatively, build strong and positive relationships with others and contribute to their community. It is enhanced when an individual is able to fulfil their personal and social goals and achieve a sense of purpose in society’.

NICE recommendations

Recommendation 1: Employers should take a strategic and co-ordinated approach to managing people.

Recommendation 2: Employers should assess opportunities for promoting employees’ mental wellbeing and managing risks.

Recommendation 3: Employers should consider flexible working.

Recommendation 4: Employers should ensure the role of line managers supports mental health and wellbeing.

Recommendation 5: Primary care trusts and services, and OH services, should support small and medium-sized businesses.

Developing the guidance

Promoting Mental Wellbeing is the first NICE guidance project that has included an occupational health nurse throughout the project from its initiation to publication.

The guidance has been developed by NICE’s Public Health Interventions Advisory Committee (Phiac). This is a group of about 30 public health experts and stakeholders who are charged with developing guidance on issues ranging from childhood nutrition to wellbeing in older people. Phiac members have considerable expertise in mental health, but no permanent members from an OH background, so in 2008 a Royal College of Nursing (RCN) nominee, Helen Kirk, the author of this article, was co-opted to help Phiac understand the perspective of OH.

The first milestone was a systematic review of the research evidence. A team led by the Institute of Occupational Medicine (IOM) in Edinburgh was commissioned to review the evidence of effectiveness for interventions that might improve mental well-being at work. Almost 8,000 reports were identified and 66 were included in the review. This may not seem like a large number for an issue as common as stress but it is a surprisingly large number compared to many evidence reviews in public health.

Unfortunately the IOM review found that many of the reports were not very robust, showed only weak or no effects, or that the findings were contradictory, some showing benefit and some the opposite.

Where there was an effect this was often with a specific intervention in a specific setting – recreational music was beneficial in an electric company in Japan, for example. This is typical of public health evidence, where it is much easier to study specific interventions in small groups than it is to do large studies of changes in populations.

At its meeting in July 2008 Phiac decided not to base recommendations on the IOM review. Instead it took the rare decision to delay the project while it consulted on a new approach, a targeted review to inform a logical model that drew on experts in work and mental well-being.

NICE commissioned another review and invited additional experts to advise Phiac. These included professors Cary Cooper, Bob Grove, and Ivan Robertson, and Peter Kelly, higher occupational health psychologist at the Health and Safety Executive’s Health Psychology Unit on mental health and doctors Richard Preece and Ira Madan on occupational health.

The new targeted review was developed at the beginning of 2009 and Phiac then developed draft guidance. During the spring the draft guidance was published for consultation and tested in the field before a final review by Phiac in June. Since then the guidance has been prepared for publication alongside support materials for practitioners and employers.

Checklist for OH practitioners

1 Develop a policy on managing (mental) health issues

1 Review HR policies on equality and on engagement

1 Raise awareness of mental wellbeing

2 Introduce mechanisms to identify mental health risks

2 Use the HSE Management Standards or other tool to assess mental health risks

2 Intervene early if a worker is absent due to a mental health issue

2 Provide access to OH interventions

3 Accommodate appropriate requests for flexible working

4 Promote and develop appropriate management styles and skills

4 Increase understanding of how management style and practices can help to promote mental wellbeing

4 Ensure that managers are able to identify and respond to employees’ concerns and symptoms

4 Use competency frameworks as a tool for management development

The recommendations

The main recommendations are fairly simple and most OH practitioners will find their work is already consistent with the evidence:

  • manage mental wellbeing system­atically
  • manage risks
  • manage people supportively
  • be flexible with working patterns
  • act to improve reduced mental health.

The guidance is careful in considering how the well-being of all workers can be promoted. This includes responding “to the needs of employees who may be experiencing poor mental health for other reasons”. This part of recommendation 1 is the most important for OH practice. It acknowledges that mental health issues at work arise for reasons unrelated to work, but that action in the workplace through OH services is helpful and it also acknowledges that a component of promoting good mental health is targeting action to support workers with reduced health.

Employers already recognise the importance of managing ‘stress’ and many will have put in place a policy or will have used a risk-management tool such as the Health and Safety Executive’s Management Standards. These employers should find they meet the requirements of recommendations 1 and 2, especially if they have support from an OH service, augmented in some cases by access to an Employee Assistance Programme or counselling.

Many employers will also have implemented supportive people-management practices based on guidance from organisations such as the Chartered Institute of Personnel and Development (CIPD) or from their own OH practitioners, offering expertise on organisational health. Such employers may have manager development programmes and ensure that their leaders understand how their style and practices can help to promote the mental wellbeing of employees and keep their stress to a minimum. Some will already have considered how they can offer flexible patterns of work to get the best from their people. These organisations will already meet requirements of recommendations 3 and 4, but the others will benefit from advice from OH practitioners using the guidance and its associated materials.

Small businesses may feel that some of the recommendations are too much for them to bear alone. However, NICE has made a specific recommendation that commissioners (for example, primary care trusts) consider how they can provide access to occupational health support. The Salus project in Scotland, announced in November as part of the fit-for-work series of pilot schemes, will provide a country-wide OH helpline and this may provide the evidence for a long-term affordable solution to this issue. In addition, NICE has worked closely with the Federation of Small Businesses to produce advice targeted at micro, small and medium-sized enterprises so that recommendations can be implemented universally.

The recommendations are important but almost as important to OH practitioners are the things not included in them. In some cases this is because there is not enough evidence to show that interventions are effective or cost-effective, but in others there is evidence that some interventions do not have a consistent positive effect.

The IOM evidence review is available on the NICE website. Its summary is worth reading for OH specialists who wish to make sure their organisations are channelling limited resources into the most effective activities to promote mental wellbeing. In addition to the NICE guidance, OH practitioners may find the IOM review helpful in guiding managers towards effective and cost-effective interventions and away from anecdotally successful ‘pet projects’ and the marketing hype of the latest fads.

There is no single way for OH practitioners to put the guidance into practice. The recommendations should be considered in the local context. Implementation resources are available on the NICE website which practitioners may find useful.

Professional development

As more evidence-based resources emerge OH practitioners are increasingly thinking about how they can get involved in producing and implementing guidance. Some suggestions include:

Helen Kirk is a consultant nurse (organisational health and wellbeing) at HK Consulting




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