Managing Major Health Risks – Roundtable Report

Dr Anne Finn, Head of Medical and Occupational Health – Unilever
Corinne Williams, Interim Head of People – SimplyHealth
Dave Moore
, Head of Occupational Health & Safety – Santander
Sally Evans, Head of Wellbeing – PwC
Dr Elizabeth Wilkinson, Head of Health Services – British Airways
Russell Turner, Head of Health & Wellbeing – Marks & Spencer
Claire Walker, Rewards Manager – Benefits, Barclays
Professor Gordon Wishart, Clinical Director – HealthScreen UK
John Picken, Managing Director – HealthScreen UK

As the NHS comes under greater pressure to cope with healthcare provision, Government has given strong indication that employers will be expected to take on greater responsibility for managing the healthcare of employees, to provide a platform, culture and facilities for people to adopt a healthy lifestyle and have a greater selfawareness of health issues.

There are many good reasons for employers to adopt such practices including improving productivity and reducing the financial costs and absenteeism caused by long term employee ill health. But in these difficult recessionary times, how can hard hit employers take on this responsibility, how much will it cost and what resources will be required to meet the Government’s demands and xpectations of health & wellbeing in the workplace? Moreover, is it really fair to expect employers to take up the slack of the health service, particularly when businesses are not being incentivised to do so?

Let us begin with a look at the Government’s directive to employers, to take a greater responsibility for employee health, review the current strategies for healthcare in the UK and the existing relationship between state and employer-led provision.

Anne Finn: Managing the healthcare of employees is very different from providing a platform, culture and facilities for people to adopt a healthy lifestyle and improve their awareness of health issues. I do not believe the former is the remit of business or occupational health providers. We do have an important role in creating the environment for a healthy lifestyle, in the provision of information and in supporting the public health agenda.

Sally Evans: We are evaluating our employee and employer value proposition, including the context of engagement and linking in the wellness of our people and its role in engagement, resilience and performance. We feel that it’s the individual’s responsibility to look after their health and we make this explicit in a number of different ways. And the other side of the deal is to promote and provide a range of options to support that. We believe that self-responsibility is more likely to achieve behavioural change, but people want to feel cared for and to be well supported too. One example; we’ve been focussing on managing energy levels, so one of our key activities is to promote regular breaks, create a culture where getting away from the laptop, walking around and taking a break becomes a basic habit.

Russell Turner: We find that acting on advice of taking regular breaks is more successful in our stores than in our head office and we’re looking at using online wellbeing services to back up our drive. Our stores are really adopting these initiatives well, but it is definitely harder to get this across to the office people, the message we keep getting is that they simply don’t have the time to get involved in the programme.

Corrine Williams: It’s definitely about education and winning hearts and minds and it needs to become compelling that wellbeing is part of their normal everyday life. People are busy that’s taken as read, and as SimplyHealth’s focus in on customer care, the message is that the wellbeing of our people is important too. We have challenges reaching our remote workers, supporting them in the same way we support our office based employees. But if you keep at it, keep consistent, the positives start to come through. Our employee survey results show that people rate wellbeing as important and that as an organisation, we’re doing well.

Anne Finn: Through our Unilever Fit Business programme, we have found that employees from different workplace environments; factory, office and laboratory, all engage equally with the messages about wellbeing and cardiovascular risk reduction. But after five years, the message is beginning to sound familiar, despite consciously refreshing it. The awareness is there, but what we are finding makes the difference now is helping employees identify and recognise the behaviours which make bad habits so difficult to break, and that they can be changed.

John Picken: That’s very important to help people understand their own personal health risks. We are all different and most programmes and campaigns try to address everyone with the same message and a large number of people cannot relate to it. It would be more effective to target the right message to specific groups within a community, based on their risks, lifestyles and behaviours.

Let’s look at the Government directive; are employers incentivised to provide workplace healthcare?

Dave Moore: Personally I don’t think it’s a realistic proposition to transfer responsibility for the health & wellbeing of the nation to the employer. And I honestly don’t think it’s going to happen. I believe the Government has a key role to play in continually monitoring the health risk profile of “UK plc”, and in developing and implementing centrally managed strategic health improvement initiatives and plans for the nation. Focusing solely on the employed population is inappropriate. Some of the key health risks in society are amongst the unemployed. These are people that may have less health options, lead less healthy lifestyles and consequently have far higher health risks than those in employment. Making quantifiable health improvements in any population can be quite a challenge, but I don’t believe the responsibility for managing these major health risks can realistically fall to the employer.

Russell Turner: The Government may have a directive, but it is not helping employers to implement initiatives. We want to implement corporate-wide physiotherapy at Marks & Spencer, whether you’ve injured yourself at work or whether you’ve just gone over on your ankle playing football. Unfortunately, in trying to implement this service we’re told by HMRC that it is a “benefit in kind” and therefore taxable. In order to navigate around the issue you have to implement a benefit that is so small in terms of cost versus your population size, that the tax revenue is trivial. Here we are with the will, money and the resources and the ability to take work and waiting lists away from the NHS physio services and yet we can’t because of a tax rule. We still breast screen our employees at M&S, we’ve got a long history of over 30 years of doing that. There was talk of taxing that for a while and we had to lobby extensively to say that we’ve got over 25,000 women who will fall into your tax bracket.

David Moore: Governments have previously signalled that tax breaks would be available to employers taking initiatives to protect the health and wellbeing of their workforce; it’s disappointing that they have never materialised.

John Picken: Employers need to pressure Government to offer tax incentives to encourage greater employer investment.

Claire Walker: We all know where the tax obligations lie, if you do the gross up to pay through other means to pay the tax on the individual’s behalf, you’re tripling the cost of the actual benefit. I do think we have to tread carefully because this could be a double-edged sword. I’m sure, if private medical schemes, for example, were not taxable, does it come with an underlying greater obligation? Most organisations have these schemes as purely a senior management benefit, would the removal of the benefit-in-kind mean that it then has to be a companywide benefit?

Elizabeth Wilkinson: I entirely agree that it is not for business to take over the role of the NHS but we can complement it. We can say the same messages and we can say it in a different way that hopefully engages our employees. One method we are considering is to offer a salary sacrifice option so you’re not taking on all the costs and you’re actually educating the employees to take responsibility themselves. They still get a benefit with healthcare checks and they get tax relief. So you can facilitate good healthcare, enhanced with additional information which can be more focused.

Well it sounds like the government directive’s hitting a brick wall unless it reviews the tax implications. So what’s the prognosis and cure, to use medical terms?

Gordon Wishart: Government directives aside, employers have got to identify key risks in their own business and all workforces and workplaces are different. You have to establish a way of managing that risk and you have to decide how much money you are willing to spend. Fact is, whilst there are good core parts of the health service that will remain intact and will still be very supportive to the majority of people in this country, we are facing an increasingly aged population, serious health risks such as obesity, diabetes and alcohol related illness, and the actual amount of money for innovation and development of new technology is going to get smaller. Set against the necessity of having a healthy workforce, businesses will be impacted and we must all lobby the Government, to bring different departments of Government together on this. There needs to be a way of increasing the amount of PMI in the UK and there needs to be more people who pay for healthcare in this country. The level of PMI has been flat for years and it needs to go up. The only way to do that is to incentivise it through tax breaks. Yes we’re in recession, and so is it really the time to go to Government to ask for tax breaks? Fact is it’s never going to be the right time to make that stand. The only way I can see a route forward is for businesses to collectively make the case and say “yes of course we’re interested in the health of your own employees, but equally you’ve got to level the playing field”.

Anne Finn: I reiterate, we are not an alternative to a state healthcare system, but we do have a lot of expertise and are in a good position to echo the big public health messages, support them with activities and programmes. We should lobby government for tax breaks, so that workforce health can be supplemented and improved, or at least not damaged. Regarding SMEs, I believe the concept of organisations helping each other is a good one.

David Moore: Presently there are no viable, Centrally-managed Government solutions on the table to provide comprehensive occupational health services to all employers. Ultimately I think they’re going to have to make their own arrangements through the private system but this could be a real challenge; particularly in the SME sector where resources simply may not be available to provide the level of cover employees’ need. On a positive note, pro-active employers understand the benefits integrated health, safety and wellbeing management can bring to the bottom line. Not just through reduced sickness absence and “presenteeism” amongst the workforce but through multiple, positive outcomes like increased motivation to deliver engagement, productivity and customer service.

Sally Evans: There is a real need to consult with the relevant people in Government around what can feasibly be passed over to employers. It seems to me this issue has some similarities with the way childcare was approached in this country. There was a lot of consideration about the part employers could reasonably play and there were assumptions made, like that it would be a good idea for lots of employers to set up workplace crèches. In fact, many employees had no desire to take small children into work, they wanted childcare that was local, affordable and high quality near where they lived.

John Picken: I agree about employee health initiatives not all being based on employer paternalism. Reducing costs is a big driver and rightly so. If employers could collectively establish the value of their investments in this area and demonstrate the savings to the state, I think they would have a much stronger argument for greater Government support.

Sally Evans: I think it’s a good point you make though about trying to quantify the kind of financial benefits and cost savings involved, and some sectors and organisations will find that easier than others. I know for us it’s really hard because we have no serious absenteeism, so for us the bigger challenge is presenteeism -so it’s people who are showing up but are maybe not firing on all cylinders. Maybe in some organisations it’s easier to measure the financial benefits, where you maybe can look at absenteeism rates, return rates from periods of absence, speed of return, etc, where these are significant impacts.

Elizabeth Wilkinson: We have absenteeism and the difficulty is quantifying the benefit of all the different work that you do, from good line management, to occupational health support, and HR support, ie all the things that factor in to managing attendance in addition to the health and wellbeing input. It is difficult to measure what it is that’s producing benefits.

Anne Finn: The difficulty with some of the return-on-investment tools is that they are based on the here and now. The health changes we are helping to bring about are long-term changes, but it is difficult to demonstrate how they will lead to savings within the NHS over the long term, using current modelling tools.

Dave Moore: In the business environment, health and wellbeing practitioners have to talk their language if they are to be understood and taken seriously. Clearly planned and well-defined health and wellbeing initiatives should set out the financial input required, the strategic outcomes that are to be achieved and, above all, the return on investment that will materialise. As a peer group, we should share and use practical examples of ROI so that operational and financial directors can see the clear business case for investment in health and wellbeing. I don’t see this as “bean counting” but an important operational competence that practitioners absolutely need to have if they are to succeed.

What are the constituent parts of an effective and sustainable health strategy and where does responsibility really lie?

John Picken: I’ve always found that large organisations struggle with this because so many people have got different health and wellbeing responsibilities. It’s great to hear Dave saying earlier that Santander are now bringing together all the various groups who can have a positive impact.

Dave Moore: Yes at Santander we realise that the new agenda is less about traditional safety risks and more about promoting high levels of physical and psychological health & wellbeing amongst our workforce. We take an integrated approach to health, safety and wellbeing management and these services are delivered by one team, working together. By combining traditional health and safety, occupational health, health & wellbeing and employee support, professional skills managers and staff have a “one stop shop” they can approach to receive the help they need.

John Picken: And strategically, there’s the point of, who is going to pay for what. When you are talking about flexible benefits and tax breaks on flexible benefits, a lot of healthcare provision within organisations is based on attraction and retention. Which businesses actually assess their health risks and then plan their health benefits around those risks? In my experience, a lot of employers have had the same health benefits for a very long time without much strategic analysis of their real value.

Dave Moore: I think it’s important to distinguish between employer provided health benefits packages and strategic health and wellbeing risk management. The two are not always the same and can be provided for very different reasons. A carefully thought out strategic health and wellbeing initiative should deliver clear, bottom line benefits to the employer, by putting limited resources where they can make the biggest impact; regardless of status or employee expectation.

What are the current trends for PMI and is this ultimately likely to be the only feasible model going forward?

Dave Moore: Private medical insurance is often seen as the “health & wellbeing solution” but I have two problems with this. Firstly, it’s prohibitively expensive, meaning that access is often restricted to senior management grades and, secondly, let’s not forget that it’s insurer-backed private treatment, so not actually a pro-active health or wellbeing initiative.

Claire Walker: We’re moving to a flexible benefits platform relatively shortly, where we have private medical included as a core funded benefit. Therefore colleagues will continue to automatically receive the benefit. Employees can choose to elect to come out, but they won’t receive the cash alternative. Private medical is a fundamental underlying principal of our health support, it is that immediacy to support a return to work and achieve that resolution, given the breadth of support available in our policy. We write our own policy to determine what we include to ensure everything supports our colleagues where we perceive the requirements to be.

Sally Evans: Strategically one of the key drivers for what we do around benefits is part of our PwC deal concept. So our people could perhaps earn higher basic salaries elsewhere, but we pay a competitive salary supplemented by a very flexible and comprehensive benefits offering, so people can take personal responsibility in putting together a benefits package that works for them, at different stages of their career. They can choose what they want, notwithstanding the fact that we do have private medical cover for everyone from day one. So for us the benefits package is a key attraction and retention tool, as well as being a key part of our wellness provision.

Let’s take a look at vocational health risks, the known ones and those that are currently being researched.

Gordon Wishart: Recently, the British Journal of Cancer looked at occupational health cancer risks. It’s a very robust piece of work that’s done by well-respected researchers in the UK and it’s essentially a meta-analysis. What they’ve said is that shift work is a carcinogen. It looked at breast cancer, for instance, and it has reported that one in 20 breast cancers are now caused by shift work, because it includes a significant amount of night work shift work. What we have been talking about today is identifying and managing risk and I don’t think that’s something we can hide from now. It’s something that we can think about and how we can manage that and how we manage the employees who have been working in that environment for a long time. It probably shouldn’t be looked at in isolation, as in terms of breast cancer there are a wide number of factors that influence your own personal risk. But if we have data that shows another risk factor then at the very least, we need to think about it. There’s now a wealth of data for all different cancers, different occupations and different exposures. The starting point always has to be hard data evidence and then it’s much easier to identify those people at risk and then help them manage that risk.

How should employers approach this?

Gordon Wishart: Firstly it is to stop treating cancer as a taboo and change the culture that it is inevitably a death sentence… avoidance is not an option. The mortality rate for most cancers has come down significantly and current cancer treatment is very good in the UK. The problem is, for reasons we’ve discussed earlier, the amount of money available for cancer and other core parts of the NHS is not going to increase, it’s not going to keep pace with what we require. Another major contribution to the decrease in mortality for certain cancers has been early detection and that’s not just screening, it’s about self-awareness. Patients coming to a breast clinic with a lump, that turns out to be a breast cancer now, has actually got smaller over the last ten years, due to all the campaigns on breast awareness. From an employer’s point of view, that usually means a lot less time off work and getting somebody back to do the job they were doing much more quickly, so those are all good things. But I think there are a lot more things we can do with education and awareness. We recently ran a corporate screening programme where everybody was invited to a 45 minute presentation on breast cancer: all the ins and outs, risk factors, how you can manage your own risk, why the risk is increasing in this country due to alcohol and obesity and how you can lower your risk. Then women did an online risk assessment questionnaire where we used a validated screening tool which looks at all factors that I mentioned, family history, reproductive history, a range of things that comes up with a relative risk, so you know if someone’s got a lower risk or a higher risk than average. They then came to an interview with a specialist nurse where their risk was discussed, the implications of that, how they could lower their risk and they were taught how to examine themselves. Finally they were examined and had the opportunity for a question and answer session. I suspect that those 20 minutes were probably the most effective part of the whole programme with a one to one chance to learn how to examine yourself, something that a lot of people don’t do, even though the charities have been supporting this for many years.

How do you think organisations should promote cancer awareness to their employees?

Gordon Wishart: I think that is very different to each company based on the workplace, the makeup of its workforce, age profile of its workforce and the strategic provision of that company and I think one of the things that we heard today is that each company is in a slightly different position and must assess its own risks and its own way of managing its investment.

Anne Finn: In the last few years our health and wellbeing strategy has shifted to a focus on risk and real value. We need to be able to demonstrate that what we are doing is aimed at the area where it is likely to have most impact. So if your business was at the point where it was beginning to look at things in terms of focusing resource on the highest risk groups, then now might be the perfect time to change. I think it depends on the organisation’s culture and where in a change cycle it might be.

Sally Evans: I can relate to what you’re saying about that and I think a lot of this is cultural. What we as employers do in the wellbeing area says a lot about who we are, often based on a lot of history that’s very personal to our own organisations and how they’ve evolved and what basic principles underpin the culture.

Elizabeth Wilkinson: I agree that it can be done but it is at a price. We’ve been through that whole cycle. We had a team of ambulance men, who were not busy most of the night because, fortunately, nothing happened, so it was a low risk workplace. So, around 16 years ago, we stopped the service and continued with the London Ambulance service only. There is still a level of upset about this decision and it is regularly mentioned. We’ve had similar experience with other issues such as blood tests for radiation and chromium checks. Change takes time, so it’s wise to be sure of the value to the employee, because if you want to stop it at any point you’re going to have to really work at it.

And what about the change in the employer/employee relationship, flexible working, more remote workers, more people being seconded to international posts?

Elizabeth Wilkinson: We have a large ‘absent’ workforce, around 20,000 aircrew, that don’t come in regularly to a set workplace. They come via the office to sign in but they live literally all over the world. So how you educate and communicate with these employees is an important issue for us. We’re looking at for example, podcasts because crew have web access when away from home, and I think it’s about using every available form of communication and repeating the important messages.

And new research, that links cancer with nightshift work, how can this be managed and communicated effectively, and where do responsibilities lie?

Gordon Wishart: This is new research data which has only just been published and what we mustn’t do is frighten people. I think someone who has had statistics that reveal a very low risk of a particular cancer, even with a 40 percent increase, might still have a very low risk, so you can’t look at that in isolation, but we do have to recognise it and perhaps manage it and if there is someone who has lots of risk factors for a particular cancer, then maybe shift work that involves night work is not the best job for them, but just how you manage that and who takes responsibility for that is really open to question.

Elizabeth Wilkinson: It is an issue for employers because we have a duty of care under the Health & Safety at Work Act if a hazard to health is identified. Action should be taken and shift work is an interesting example as it has been so controversial. I haven’t seen the latest meta-analysis that you mentioned but to date, unlike noise, vibration or the other absolutes, there has been less work guidance about it. However, it is now quite clear that we should take action. The potential risks for night workers are already addressed by most employers I would think, but shift work per se is slightly different.

John Picken: The HSE is doing its own investigation and will be reporting in two years’ time.

Gordon Wishart: But I think what they’re saying is if you work shifts it usually involves a proportion of night work. I think it’s the night work that’s the most important part of it. It’s being exposed to light during the night when you’re body isn’t used to it. It upsets your biological rhythms and that has an impact on certain cancers, not all cancers, but certain ones, like breast cancer. If you were looking at it from a medical legal point of view, if someone was employed 20 years ago when this data was not known, then I don’t think there’s an issue, but I think the problem will arise now if you took someone on and let’s say, in a few years, they got breast cancer, you would then go back and say well the data was published at that time, you knew there was an increased risk, how did you discuss that risk with your employee? You can see how that would evolve, so I think it is something that needs to be quite carefully considered.

David Moore: In legal terms that’s “date of knowledge” and after this point in time an employer would, effectively, have a duty of care and be required to take appropriate action. Particularly once the HSE has prepared and issued formal written guidance to employers. But it’s good to have advance notice of this potential health risk.

Anne Finn: Programmes which are dependent on fixed materials or locations will not reach everyone. There are always elements which need to be provided from a location, such as health checks, but for the rest, we are moving to online assessment tools, system triage of high risk responses, reports and solutions offered instantaneously, and information available to all, using all available media. The resource-intensive and fixed location interventions are therefore geared to the highest risk groups. An example is overseas business travellers. Healthy lifestyle and healthcare advice has to fit with the fact that they are often not at their home base.

Dave Moore: For any strategic health and wellbeing initiative it’s obviously important that you reach your target audience. In the service sector this means paying particular attention not just to your head office buildings but also to your branch network too.

What is the best way for employers to encourage their employees to take control of their own health and promote health risk awareness?

Sally Evans: In our culture, people are a bit fed up with being bombarded with information by email and intranet. We’re realising what’s really important is the quality of relationships and conversations that they have with their people managers. Our people don’t necessarily have a line manager in the traditional sense, as they’ll be working across different engagements and projects. So we have a people manager role, where people are designated people managers in addition to their normal role. They’ll typically have responsibility for six or so individuals who they will people manage and those individuals could very often be people that they rarely see face to face. What we’re doing is investing a lot of energy in training our people managers to be better at what we call “spotting the signs” and this has a particular emphasis around psychological and emotional health, but it covers health and wellbeing generally.

Introducing an initiative is one thing, how sustaining interest and participation is the tough bit?

Corrine Williams: We started a programme to support and help managers to have what they may describe as difficult conversations with their teams. The breadth of those conversations may cover areas of health and wellbeing, attendance and absenteeism for example. We are trying to equip managers to ask the right questions, to give them confidence to talk openly and honestly. From an HR perspective, we need to make sure we’ve got the right support mechanisms in place. We run an EAP helpline both for employees and managers.

Russell Turner: We’re becoming increasingly convinced that the technologydriven route is the direction to go, wellbeing itself is the way forward and online. I think you’ve got to keep things simple, and you’ve got to know your organisation very well, but there’s no one answer for every business. Use your analysis and data to see where you might have elements of stress, muscular skeletal issues, people who are on their feet all day stacking shelves etc. and make sure your activity is appropriate, practical and effective.

Dave Moore: I’ve found that introducing an element of competition between operating divisions can be a powerful driver to improve overall safety performance; and applying these same principles to health risk management could have similar benefits as teams could be provided with their overall health risk scores and on-going data about how to reduce health risks. Providing comparative data between teams could be a powerful motivator to make and, more importantly maintain, healthy lifestyle choices. It’s peer pressure but also about fostering a sense of competition between groups.

Corinne Williams: One of our priorities is for us to support local community and charity work and we actively encourage people to take part in activities in their local community and the ‘feel good’ factor and buzz is really compelling.

Sally Evans: We’ve been using gadgets that measure physical activity, pedometers that really encourage people to walk rather than take the car and use the stairs instead of the lift, walking across the office to talk to people rather than e-mailing, and you get some good competition getting people motivated in that way can really encourage them to make big lifestyle changes.

Anne Finn: Agreed, participating in something makes people feel they are part of something bigger. I think the key is to seek behaviour change, because once good habits are truly embedded, the behaviour change does not usually reverse. So it’s not just about hearing the message but changing the behaviour and if you need to give people more help to do that, like health coaching which has been proven to work, then invest in a little bit more of that to effect the behaviour change.

Russell Turner: We’re encouraging people to go to the website and make a health pledge and lots of research seems to show that after four weeks if you do something consistently it becomes habitual.

Dave Moore: Medical research indicates that people who are chronically obese who diet significantly have only a ten percent chance of maintaining their post diet weight at the end of a five year period. To help address these high failure rates, an effective health promotion initiative needs to provide staff with ongoing training, coaching and support, possibly throughout their period of employment.

Russell Turner: We absolutely have no problem with incentivising it at all. I know lots of people who kind of struggle with this one but offer a £500 a weekend health spa for two people gets 3000 people involved.

Gordon Wishart: I’ve been very encouraged to hear some of the different strategies that you’re using to encourage people to be interested in their health. I like what you’re doing, in terms of giving people the right questions to ask. If you ask anybody in this country, “how are you doing”, the answer will be “I’m fine” whether they well or not. It’s a culture that we’ve got to overcome in this country that allows you to actually understand how they are feeling and what you can do about that. I also like the idea of using competitions to incentivise people and I like these team building exercises that you’re doing as well. It seems clear that some innovation and going the extra mile goes a long way in educating and informing and changing behaviour. If this good work is allowed to continue, hopefully the poor health trends will go down, which will obviously be good all round.

John Picken: What is clear to me is that each employer has their own culture and organisational specific issues they need to address. I was very interested in what everyone thought or believed the Government is doing for employers at the moment. By all accounts, not a great deal and leaving most employers to manage major health risks themselves. Can I just ask whether anybody has heard of Improving Outcomes the cancer strategy from the government? Nobody! So they’re asking employers to do more around cancer but some of the biggest employers globally have not heard about it. That’s not a great strategy.

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