Can Changing the Nature of the Workplace Help the NHS Tackle its Workforce issues ?

Background

In 2009 Stephen Boorman was surprised by the high levels of burnout, sickness absence, stress, and demoralisation he found in the NHS workforce. Much of this he associated with the high levels of service change and decreased resources - and that was 2009.

Too often when people are off sick we apply a 'clinical model'. We ask them "what is wrong with you?" and "what treatment do you need ?". We tend to treat the individual and then return them to the same environment. Much less is likely to be said about how we can change the nature of the work or the work place. We may talk about 'reasonable adjustments' but are we really willing to change the workplace ?

The NHS tends to assume that people consider it a privilege to work there. Of course, it is very rewarding and many of us do indeed consider it to be a privilege to be part of it. The problem is that it can sometimes appear that it assumes an endless supply of staff who are delighted to work for it.

However, the current problems with recruitment and retention show that we cannot continue to take it for granted that there will be an endless supply of people wanting to work for the NHS and that there is a real personal cost to the pressure that the system is currently under.

The risk is that we are causing our staff real mental distress by our insistence that they can continue to do "more for less" or not properly involving them in the setting of expectations in terms of outcomes or efficiency. There is a real cognitive dissonance at the heart of much of the decision making.

When there are high levels of depression and anxiety present in the workforce there is good evidence to show that this is not caused by a lack of resilience in the individuals concerned but rather by problems with the workplace and the behaviours that are present there.

Addressing the Issue

In his recent meta-analysis Sam Harvey from the University of New South Wales1 reviewed the evidence about what contributes to mental well-being in the workplace and what is likely to contribute to mental illness at work. It is worthy of attention. This shows that there is strong evidence that: i) imbalanced job design, ii) occupational uncertainty and iii) a lack of value and respect in the workplace is likely to contribute to mental illness at work.

1http://www.wmh.unsw.edu.au/sites/all/files/publication_related_files/can_work_make_you_mentally_ill_a_systematic_oem.pdf

He also found that there is moderate evidence that more likely to develop mental illness if the environment is one where there are :

- High job demands- Low job control- High effort / reward ratio imbalance- Low relational justice (no point raising issues as no-one will take it seriously).- Low procedural justice (lack of fair policies and procedures)- Role stress- Bullying- Low social support in the workplace

As the diagram shows the intervention for which there is the most evidence is procedural justice. However, Sam Harvey emphasises that there is not one "toxic" factor.

There needs to be a comprehensive approach. However, it also emphasises that those with or at risk of developing mental illness do not need to avoid work - work improves their mental well-being - but that there are factors that impact on the ability of all of us to operate effectively at work.

So, thus far there has been a tendency to focus on the individual and on secondary prevention. What work that has taken place has focused on a small number of employers and much of this focusses on support to the individual and how the individual can be

supported to fit around work. This is important. However, equally important is to focus on the employer. Most employers want to reduce churn and to retain good staff. Those with relatively small workforces are even more likely to be well disposed to want to support people to stay in work or to return to work well. As such they are an important resource and we need to work with them as well as the taking an individual approach.

We want to extend recovery principles to both developing and supporting the workforce. This will involve normalising the kind of adjustments that people need and taking a universal approach to these adjustments just as we do for physical disabilities. Strip jobs down and build in flexibility. We also need to ensure that employers can access someone to talk to if they are struggling. It's not about selling a class of people but how you help a person they know.

A key question for us in the NHS is whether we can change the nature of the work. How do we create the jobs that people can do and that we can recruit to locally. In addition we need to develop a better appreciation of what younger generations are looking for. We also need to move to scale to draw people with lived experience into the workforce.

Conclusion

In the UK, the debate has been focussed on a small number of national employers, BT / Royal Mail etc. These employers are better at valuing their staff, the skills that they have and the costs associated with high churn.

Changing the nature of the work is hard and requires a lot of political and personal will. Stigma and discrimination still inhibit actions that are not illness focussed. Too often the culture is one that avoids risk rather than use health promotion as a mitigation. We invest in mental health literacy rather than mental illness awareness.

It is important to support individuals but need to also look at the nature of work and the work environment. We shared that this is hard. Need a comprehensive and iterative approach that is driven by staff and who are empowered to experiment and evaluate solutions through an iterative process.

Too often people are made to feel that they are a burden on an organisation. In this situation stigma is a cover for discrimination. We need to identify the risks correctly and have health promotion initiatives and make changes to the workplace environment. However, there is resistance to addressing what we know constitutes a good working environment.

Workplace mental health tends to focus on secondary prevention. The Government has said that it wants to see better support of the mental health of people in employment those with mental health problems to thrive in work. The Stephenson Farmer Report focusses on support for the individual and called on the on the NHS to support workplace mental health by ensuring support is accessible, high quality and fits around work.

There are a number of steps to achieve this :-

1) Employers need to understand the benefits to their organisations of taking the workplace environment seriously and recognise that this is core business with clear benefits including RoI.

2) Take a comprehensive approach to workplace mental health- look at the whole continuum of mental health and well-being in the workplace and ensure that it is fully integrated. This is about creating environments that help everybody to perform well and include promotion, prevention and support in our approaches.

3) We need to support the individual but also change the harmful impact of job roles and the work environment.

4) There is a need to encourage bottom-up responses that are related to the local workplace - the values need to be consistent but the cultures can vary to an extent. We need to allow the employees to choose the themes that are being worked.

5) We should replace sickness absence measures with something else - possibly a suite of metrics to include retention rates.

6) Need to give people the power to try solutions and evaluate them - this may take a number of iterations. It is not a project. Needs to be embedded in Quality Improvement approaches.

For the good of society, people need to be able to fulfil their potential and maintain their (mental) health and well-being. All employers need to understand that adapting the workplace environment and management approaches should be a central element of achieving organisational goals.

Peter MolyneuxNovember 2018

Peter Molyneux would like to thank Rachel Perkins and Miles Rinaldi for their help in the production of this paper. He would also like to thank the members of the "match" on workplace mental health at the 2018 International Initiative on Mental Health Leadership Conference for their input to this paper.