Work-related stress, depression or anxiety accounts for a staggering 40% of work-related ill-health and 49% of working days lost, before we even get to the impact of stressful modern lives on work and productivity. While managing mental ill-health is never easy, occupational health can play a pivotal prevention, intervention and support role, argues Charles Alberts.
The profile of mental health has risen at a phenomenal speed – from a taboo topic for many not that long ago to it now being a standard item on the occupational health and wellbeing agenda for most of the employers we work with.
Perhaps it is not surprising. Mental health is something we all have; it touches the very core of us as human beings, and most of us can relate to both positive and poor mental health at times in our lives. We’ve also been able to translate this into a business context, with research conducted by Deloitte quoted in the government’s Thriving at Work report estimating the average cost of poor mental health to employers at between £1,205 and £1,560 per employee per year – a staggering £33 billion to £42 billion annually.
About the author
Charles Alberts is head of health management at Aon
Awareness is the first step to tackling any issue, and mental health is no exception. Awareness of the human and economic costs has perked up the ears of boards up and down the country and we’re starting to see examples of employers adopting best practice approaches. But the road ahead is long.
Let’s look at work-related stress as an example. Firstly, for the purists out there, we acknowledge that “stress” is not considered a medical condition.
However, stress experienced over a longer time can result in mental health problems, and it can aggravate an existing mental health problem, making it more difficult to separate one from the other, and in turn to address the root cause.
It also has a physical impact, directly correlated with increased occurrence of health problems such as flu, sore throat, headaches, and backaches. Research also shows that the physiological changes caused by stress can lead to heart attacks and stroke, and is considered as important a risk factor as having high blood pressure or being a smoker.
This dynamic adds up to be a major issue for employers. Work-related stress, depression or anxiety accounts for a staggering 40% of work-related ill health (526,000 workers) and 49% of working days lost (12.5 million days), according to the Health and Safety Executive’s (HSE’s) Labour Force Survey in 2016/17. And it’s not getting any better – as shown in the 2018 CIPD/Simplyhealth Health and Wellbeing at Work report, 55% of employers have seen an increase in common mental health conditions, which is strongly related to increases in stress-related absence where 37% of employers have reported an increase. Both issues are associated with increased ‘presenteeism’ which 86% of employers have cited as an issue in their businesses.
Role of occupational health
If we’re to find a solution and consider the role of occupational health in this context, it is sensible to consider what causes stress. From a work perspective, HSE outlines six areas of work design that impact stress:
- Demands: workload, work patterns, and the work environment
- Control: how much say the person has in the way they do their work
- Support: encouragement, sponsorship and resources provided by the organisation, line management and colleagues
- Relationships: promoting positive working to avoid conflict and dealing with unacceptable behaviour
- Role: whether people understand their role within the organisation and whether the organisation ensures that they do not have conflicting roles
- Change: how organisational change (large or small) is managed and communicated in the organisation.
According to the Labour Force Survey, the top cause for work-related stress is workload, followed by a lack of managerial support and organisational change. This is consistent with the CIPD’s findings on the top causes of stress-related absence.
We know that employers have a legal duty to protect employees from stress at work by conducting a risk assessment and taking appropriate action (Management of Health and Safety at Work Regulations 1999 and the Health and Safety at Work etc Act 1974).
Assessing psychosocial risks
Various tools to help employers identify the causes of work-related stress exist, including the HSE’s Management Standards indicator tool. Yet, based on our experience, many employers fail to adequately assess these psychosocial hazards as they do for physiological hazards such as noise, vibration and dust.
Our experience is echoed in the 2017 study Psychosocial, Health Promotion and Safety Culture management – Are Health and Safety Practitioners involved? which surveyed 879 health and safety practitioners (HSPs) in the UK and Ireland. It found that only 30.8% of HSPs performed psychosocial risk assessment and management (compared to 86.8% performing safety culture tasks and 64.2% performing health promotion-related tasks).
The reasoning behind this is explored in studies such as Is psychosocial risk prevention possible? Deconstructing common presumptions where it is concluded that, “although guidance on psychosocial risks and their management exists in abundance as does evidence to support the ‘case’ for psychosocial risk management, the concept of psychosocial risk is still not clearly understood in its entirety with discussions being focused on negative impacts and not opportunities that can be capitalised upon through effective psychosocial risk management at the organisational and societal levels.”
The authors continue: “A key issue is the false distinction often made between psychosocial factors and issues pertaining to work organisation, since psychosocial risks are embedded in certain forms of work organization.”
In my view, this provides an ideal opportunity for occupational health providers to step up to the plate and proactively help employers to tackle one of their most significant health risks.
In its recent report Occupational health: the value proposition, the Society of Occupational Medicine (SOM) cites an HSE definition of “comprehensive” occupational health support as encompassing hazard identification, risk management, provision of information modifying work activities, providing training on occupational health-related issues, measuring workplace hazards, and monitoring trends in health.
By this definition, a surprisingly low proportion of employers in the UK (3%, according to SOM) utilise a “comprehensive” occupational health service. We should ask ourselves why – is it due to an absence of employer need, or how occupational health is positioned, affording an opportunity to broaden the scope of service delivery?
Occupational health assessment
Referrals for an occupational health assessment where work-related stress is the underlying reason (frequently undeclared by the referrer) can be a bone of contention for occupational health professionals. There is, rightly, a concern over medicalising an issue where the root cause (and resolution) is not clinical, and a frustration that the employer seems unwilling or incapable of managing it in the workplace.
From the employer’s perspective, the situation isn’t always as clear-cut, especially if the referrer (such as human resources) is not directly involved in managing the employee. We have already explored the ambiguity that the interplay between stress, mental and physical health can create – symptoms can present in various forms and as non-clinicians with a duty of care towards the employee and a responsibility to protect the business. Occupational health advice can be invaluable, even if the conclusion is non-medical.
How can occupational health assist?
- Play a leading role in educating employers on work-related stress, psychosocial hazard assessment and management. This can take numerous forms – a varied approach is beneficial including case-specific evaluation, written client guides, employer presentations (webinar, in-person) and bespoke training for HR and line managers on OH and work-related stress issues.
- Agree up-front with the employer what support is required when work-related cases are presented and how these cases should be managed between the stakeholders. It’s a two-way street and equally important to guide the employer on how to make a “good” referral when work-related stress issues are a suspected cause. Setting expectations will help to avoid unnecessary conflict and perceptions of service failure.
- Use the tools available. For example, consider utilisation of an individual stress risk assessment such as the HSE’s Management Standards indicator tool, ideally in advance of conducting the occupational health assessment, to identify specific issues and to inform the professional recommendation.
- De-medicalise. Articulate the value of de-medicalising situations (where appropriate), potentially empowering the employer to manage cases to resolution in a timely manner.
- Be clear. Consider that employers are often uncertain and concerned about mental health issues and value clarity around what is medical (and will benefit from medical treatment), and what is not medical (which needs to be tackled a different manner, led by the organisation).
- Recognise when a medical intervention is required. Where there is a medical problem, identify any underlying issues that may negatively impact the condition and/or ability to return to work – there is value for employers in a holistic view when assessing the employee and providing evidence-based advice about the kind of lifestyle, medical, and organisation interventions that would help.
- Gain a solid understanding of the range of benefits and services that the employer offers and include appropriate signposting in the recommendations. Many employers offer benefits such as Employee Assistance Programmes, private medical insurance, and group income protection that can be used to facilitate diagnosis and treatment of mental health conditions. The exact benefits offered within policies and how these are accessed (for example direct or via GP referral) can vary, therefore it is advisable to ask the employer for specific information about their specific arrangements.
- Consider whether there are any opportunities to integrate the occupational health service with the employer’s other benefits and services. This could be by, for instance, direct referral by the occupational health professional to private medical insurance without the need for a GP referral, or agreeing dual patient consent with the group income protection provider to facilitate sharing of information.
- Consider wider wellbeing. An increasing number of employers offer wellbeing programmes that may include elements of mindfulness, meditation, resilience and stress management interventions. There is value in gathering details on such programmes from employers should it be relevant for the recommendation.
How can occupational health providers help with prevention?
There are three levels of intervention for work-related stress:
- Primary (prevention at the source)
- Secondary (bolstering individual coping capability and resilience)
- Tertiary (remedial support)
In the UK, treatment of mental health issues is provided by the public healthcare system, delivered in a range of settings, free at the point of use. Some employers also offer private medical insurance to employees, with the promise of faster access to care.
And, with the rise in workplace wellbeing programmes, we have observed many commercial occupational health providers enhance their services to include health promotion activities. The vast majority of these include stress and mental health.
Perhaps where the greatest opportunity lies is in helping employers to reduce psychosocial hazards and incidence of work-related stress in the first instance. Whilst covered by the same legislation as physical hazards which are commonly assessed and managed via health surveillance programmes, to-date there is a scarcity of comprehensive solutions to help employers with what is a very real issue.
In my view, this presents a tangible commercial opportunity for occupational health providers, further enhancing the industry’s position as an invaluable partner to business, and puts us at the very heart of what matters in the contemporary world of work.
While it is true to say that we don’t have all the answers, but this issue is not going away and is well worth debating.
Thriving at Work: a review of mental health and employers. An independent review of mental health and employers by Lord Dennis Stevenson and Paul Farmer, October 2017, https://www.gov.uk/government/publications/thriving-at-work-a-review-of-mental-health-and-employers
How to manage stress, Mind, https://www.mind.org.uk/information-support/types-of-mental-health-problems/stress/#.W5kL3c5Kjct
Mental health conditions, work and the workplace, The Health and Safety Executive, http://www.hse.gov.uk/stress/mental-health.htm
DeLongis, Anita, Folkman, Susan, Lazarus, Richard S. The impact of daily stress on health and mood: Psychological and social resources as mediators, Journal of Personality and Social Psychology, Vol 54(3), Mar 1988, 486-495
Feeling stressed? Research shows how stress can lead to heart attacks and stroke, The British Heart Foundation, https://www.bhf.org.uk/informationsupport/heart-matters-magazine/news/behind-the-headlines/stress-and-heart-disease
ork-related Stress, Depression or Anxiety Statistics in Great Britain 2017, Health and Safety Executive, http://www.hse.gov.uk/statistics/causdis/stress/stress.pdf
Health and well-being at work, CIPD and Simplyhealth, May 2018, https://www.cipd.co.uk/Images/health-and-well-being-at-work_tcm18-40863.pdf
Stress Management Standards Health and Safety Executive, http://www.hse.gov.uk/stress/standards/
Labour Force Survey, 2016/17, Health and Safety Executive, http://www.hse.gov.uk/statistics/causdis/stress/
Tackling work-related stress using the Management Standards approach, Health and Safety Executive, http://www.hse.gov.uk/pubns/wbk01.htm
Leitão, Sara and Birgit A. Greiner. Psychosocial, Health Promotion and Safety Culture management – Are Health and Safety Practitioners involved? Safety Science, vol 91, January 2017, Pages 84-92, https://doi.org/10.1016/j.ssci.2016.07.002
Leka, Stavroula, Van Wassenhove, Wim and Jain, Aditya. Is psychosocial risk prevention possible? Deconstructing common presumptions. Safety Science, http://eprints.nottingham.ac.uk/31892/1/Safety%20Science_Is%20psychosocial%20risk%20prevention%20possible_Leka%20et%20al.pdf
Occupational Health: the value proposition, Society of Occupational Medicine, May 2017, https://www.som.org.uk/sites/som.org.uk/files/Occupational_health_%20the_value_proposition.pdf
HSE Management Standards Indicator Tool, http://www.hse.gov.uk/stress/standards/pdfs/indicatortool.pdf