The recent annual conference of the Institute for Employment Studies took place just after the health and disability Green Paper was launched. Noel O’Reilly reports on talks covering “daft” therapies, claims that the wellbeing agenda is swamping the message about workplace exposure to hazards, and the truth about physiotherapists.
Launching the 2016 Institute for Employment Studies (IES) annual conference, Professor Stephen Bevan, head of HR research at IES, looked back over a decade of progress towards getting work and wellbeing on the agenda.
It was fortuitous that the event took place just after the publication of the Work, health and disability: improving lives Green Paper in October 2016.
“I’m gratified that some of the ideas, which 10 years ago were regarded with scepticism by some, are now considered mainstream,” said Bevan. “For example, an acceptance that work is a social determinant of health – especially important if we are concerned to reduce health inequalities – and that ‘good work’ is good for health [the Green Paper calls this ‘appropriate work’ – can’t win them all], and that work should be regarded [especially by healthcare providers] as a clinical outcome of care. Again, a long way to go here, but now accepted and woven into the Green Paper.
“In addition, it’s easier now to make the case for early intervention, self-management, phased return to work and other vocational rehabilitation interventions, that job design and high-quality line management are essential – especially for psychosocial health – and that taking a biopsychosocial approach to workforce health is the best way to deliver the best outcomes for people with multi-morbid conditions.”
Bevan went on to highlight areas that remain a cause for concern: “One-third of UK employees say they would never work with someone who has a mental illness – ironically, they probably have been for some time without realising it – and a quarter of employers still say that workforce health – other than their legal duty of care – is none of the organisation’s business.”
Close the gap between rhetoric and reality
“What we need is for employers to look at the evidence, not poorly researched surveys in HR magazines.” This was the message from Dr John Ballard, editor of Occupational Health [at Work]. Ballard made the case for the use of evidence-based practice to close the gap between workplace health rhetoric and reality.
He challenged the validity of the PricewaterhouseCoopers (PwC) report cited in Dame Carol Black’s Working for a healthier tomorrow (2008) paper, which used case study evidence to show “the financial benefits of wellbeing programmes, including reduced sickness absence, improved productivity and reduced staff turnover”.
Ballard went on to dismiss as “plain daft” complementary therapies from the “left-field health world” which were given to 30% of participants in a Department for Work and Pension’s £18 million job retention and rehabilitation pilot. These included “thought-field therapy” and “stress-ball fights”.
He also questioned the value of influenza vaccination, adopted by large companies and the NHS. A Cochrane systematic review (Demicheli V et al, 2014) found vaccinating healthy adults saves, on average, only about 0.04 working days per person. “They’re spending an awful lot of money, that they could probably be spending elsewhere, on interventions that probably don’t work,” said Ballard.
He challenged the limited and low-quality data available to support wellbeing products such as sit-stand desks and pedometers. “Being popular isn’t the measure of effectiveness,” he said.
Ballard argued that the focus for HR and OH professionals should be workplace causes of ill health in employment sectors where sickness absence is still high.
The construction sector is responsible for 56% of all new male occupational cancers and an is example of an industry where work-related disease should be addressed, he said. He added: “The simple message for the construction industry is to prevent occupational exposures… the whole wellbeing and work agenda swamps the message.”
He urged employers to address the management styles and working practices that cause psychological hazards at work, resulting in high sickness absence. A body of research has found that these risks relate to issues such as low job control, high work demands and unfairness at work, among other related factors.
His conclusion was that efforts to improve employee health should focus on good job design, better pay and supportive management, as well as tackling hazardous exposures.
Ballard acknowledged that the Faculty of Occupational Medicine ethics guidance supports OH practitioners having a wider public health role “to protect health and promote the wellbeing of people of working age”.
But he questioned whether or not there was sufficient quality evidence to underpin this. “We haven’t got a solid curriculum to educate OH and HR professionals in this area of health and wellbeing,” he said.
Ballard began and ended his talk by citing an article (Dodge, 2012) that concluded “stable wellbeing” at work is “when individuals have the psychological, social and physical resources they need to meet a particular psychological challenge. When individuals have more challenges than resources, the see-saw dips, along with their wellbeing, and vice versa.”
Global work and wellbeing case studies
Two case studies looked at the challenges of employee wellbeing programmes in global companies.
Unilever operates in 100 countries and has 100,000 employees. Dr Vedat Mizrahi, director, medical and occupational health Europe, UK & Ireland at Unilever, explained how the company’s “Lamplighter” health promotion programme was integrated with its sustainable living plan, and linked with objectives to reduce environmental impacts and “enhancing livelihoods” worldwide.
The company’s 2016-2020 Medical and Occupational Health (M&OH) strategy has a global and regional framework, and a national plan for individual countries.
Key performance indicators (KPIs) include: the percentage of employees reached by an employee wellness programme; the prevalence of health risk factors such as hypertension, obesity and diabetes; prevention of work-related illness (WRI), and reduction of days lost due to WRI; and the provision of appropriate M&OH structures globally across the organisation.
Helen Wray, health and wellbeing lead, Mars Chocolate UK, discussed the challenge of managing a global company with 75,000 staff. The company has conducted a survey of 49 sites and is developing global metrics showing the relationship between talent retention and employees’ health status.
The challenges vary between regions. In the company’s UK factory in Slough, the average age is 48, and many staff have caring responsibilities outside work. In India and China, the workforce is younger. In China, non-communicable disease, diabetes and high blood pressure are issues where inactivity is a major risk factor.
Wray said the emphasis is on sustainability, advising: “Make sure it isn’t a once-a-year, flash-in-the-pan objective and that it’s sustainable throughout the year.”
Making the business case to SMEs
Jane Abraham, policy fellow at the Department for Work and Pensions Work and Health Unit, discussed efforts by the Government to make the business case for health and wellbeing to small and medium-sized employers (SMEs).
SMEs employ 15.6 million people, 60% in the private sector. Ninety-nine per cent of those are businesses of 0-49 people. They have higher risk factors, more hazardous conditions, higher injuries and more health-related problems than larger companies.
As SMEs are more economically fragile than large organisations, with shorter life spans than larger companies, it is difficult to make the case for return on investment.
The Government is consulting with SMEs on trusted and accessible sources of information, such as banks, Company House or indemnity insurers, in order to raise awareness of support available.
Research has found that SMEs are task focused and want specific information to answer a query quickly and easily. They need to trust information sources, are keen to learn from peers, need content tailored to their needs, and respond better if the message comes from business rather than health professionals.
Self-referral to physiotherapists
Professor Karen Middleton, chief executive of the Chartered Society of Physiotherapy (CSP), said that it is not always understood that physiotherapists are autonomous, and regulated by the Health and Care Professions Council (HCPC).
Physiotherapists can assess and diagnose patients, and have been able to take referrals from patients without them having to see a doctor since 1977. And now, they can prescribe independently.
There were 52,299 physiotherapists registered with the HCPC in January 2016, but only about 800 are OH physiotherapists. “They [OH physiotherapists] are not going to be able to deal with all the problems,” said Middleton.
The physiotherapy ethos is to look at what people can do, as opposed to what they cannot, so they are trained to think about the outcome for an occupation.
“We need to make work an outcome,” said Middleton. She welcomed the recent Green Paper proposal that physiotherapists should be able to sign fit notes.
She said myths about physiotherapy self-referral needed to be busted, as, contrary to what many assume, the evidence shows self-referral: reduces waiting time; does not decrease demand; decreases costs per patient; and is safe, because physiotherapists are trained to spot serious pathologies and will refer instantly to a hospital consultant.
Department of Health research (2008) on an initiative to encourage self-referral to physiotherapy shows it provided savings of £25,207 per 100,000 of the population as a result of reducing GP contact, unnecessary prescribing and unnecessary diagnostic imaging.
“My frustration is that there is so much evidence about self-referral and early intervention, but we’re not yet there yet. And something we’ve had in place for 30 years is still not mainstream,” said Middleton.
She added: “What we’re saying this year is we want self-referral to physiotherapy in every GP practice.”
The CSP is also calling for a reduction in referrals to secondary care and community interface services, and an increase in the number of patients able to self-manage effectively, as well as more referrals to leisure centres and other providers of other forms of physical activity.
In a presentation on cognitive enhancers, Dr Paul Nicholson, chairman of the BMA Occupational Medicine Committee, looked at the evidence on whether or not drugs such as Dexamphetamine, Methylphenidate (Ritalin) and Modafinil, sometimes referred to as “smart drugs”, could enhance workplace performance.
Overall, Nicholson concluded that smart drugs had “dubious benefit for real people performing real work in the real world”.
Black C (2008). Working for a healthier tomorrow. London, TSO.
Demicheli V et al (2014). Vaccine to prevent influenza in healthy adults. Cochrane Database Systematic Review; (3) CD001269.
Department of Health (2016).Work, health and disability: improving lives Green Paper. Department for Work and Pensions.
Department of Health (2008). Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. London DH.
Dodge R et al (2012). The challenge of defining wellbeing. International Journal of Wellbeing, vol.2(3), pp.222-235.