Table talk: mental health
We summarise an expert discussion convened by IOSH on how employers support mental health and the role of mental health first aider.
Representatives of major employers, unions and employment bodies met at the Institute of Directors (IoD) in London’s Pall Mall on 23 November to discuss employer support for workers with mental health issues. The round table discussion coincided with the publication of an IOSH-sponsored study by researchers at The University of Nottingham into the role and function of mental health first aiders (MHFAs).
After a summary of the findings of the study by Avril Drummond, professor of healthcare research and Dr Melanie Narayanasamy, the discussion kicked off with a question about whether participants saw social, regulatory or employee pressure for more mental health support.
Hugh Robertson, senior policy officer for health and safety at the Trades Union Congress, said the recommendations of the 2017 government-commissioned Stevenson Farmer review of employer mental health provision were beginning to have an impact in the public sector. “I think there’s growing awareness because of that and the work Mind and Mental Health First Aid are doing, and employers are starting to consider it,” he said.
But employers often went to inappropriate providers, “consultants and snake oil salesmen”. He warned against looking for easy options rather than improving occupational health support and exploring how organisational pressures contribute to poor mental health.
Sally Evans, wellbeing lead at professional services multinational PwC, said the perception of a need for support varied by sector and organisation: “A lot of organisations are not going to invest in this type of intervention unless there’s some perceived value from a business performance perspective.” PwC has a young workforce that “expects a culture where positive things are happening in this space.”
MHFA under scrutiny
In the light of the launch of the MENTOR research into the use of mental health first aid (MHFA), the round table participants returned to its place in mental health provision and its value to organisations several times in their discussion.
On the place of MHFA in employer responses to demand for mental health support, Hugh Robertson said: “The problem is, that employers are seeing mental health first aid, through no fault of yourselves [Mental Health First Aid England], as a first-line approach. We need them to look at the wider issues, which mental health first aid can be a part of.”
Some organisations saw MHFA training as a solution to the problem of line managers’ inability to manage mental health problems, “which is deeply inappropriate”.
Dr Shaun Davis from Royal Mail noted physical first aid operated in a context of prior risk assessments, hazard identification, education, training and other controls. “I think that bit isn’t as obvious with mental health first aid,” he said. Sally Evans said that at PwC, MHFA training was just one of a variety of mental health awareness courses it offered.
“When we talk about [wanting] parity with physical first aid we don’t just mean having first aiders in the workplace,” said Fionuala Bonnar of MHFA England. “We mean in terms of the whole organisational approach and the prevention strategies”.
Karl Simons said growing willingness to talk about mental health issues and Thames Water’s appointment of MHFAs was “acting as a catalyst for conversation within teams”.
Evans said PwC had found it needed to provide support for the MHFAs. “There is ongoing supervision, because otherwise there’s a question of duty of care when those people are having quite difficult conversations.”
Davis said that integrating MHFAs’ work involved informing them of organisational developments such as change programmes, “deploying them, giving them a script, so they can talk about what it means.”
Professor Avril Drummond said the MENTOR research found some organisations were appointing the wrong people as aiders, sometimes the result of accepting volunteers who responded to blanket emails: “We spoke to one lady who was a receptionist and had been trained but said ‘I’m on the desk nine to five and it’s really hard to get away from it’. So either she shouldn’t have been sent on the training or there should have been recognition she would need protected time and cover to fulfil that role.”
Dr Melanie Narayanasamy from The University of Nottingham noted that research for Mental Health First Aid Australia found the boundaries of the support offered by MHFAs were less clearly drawn than those of physical first aiders: “It’s a different relationship.”
Drummond highlighted the MENTOR study’s inability to find firm evidence for the business benefits of MHFA. Simons said he could provide her with evidence of the effectiveness of appointing MHFAs in Thames Water.
Bonnar argued that MHFA was one of the most evaluated interventions to improve mental health awareness and confidence in talking about problems but she admitted there was a gap in showing its effect on individuals with mental health problems.
Asked whether there was evidence of business impact measured in reductions in sick leave and other costs, Bonnar said only at organisational level, not in aggregated form.
Robertson said it was important not to over-emphasise the need for proof of return on investment as there was also none for the benefit of training physical first aiders. Peter Brown from the HSE said cost-benefit evaluation is hard because few organisations make one intervention at a time, so it is hard to differentiate the effect of one initiative.
Bonnar said organisations should record MHFA interventions as they do physical first aiders’ activity with a standard form. Robertson noted that though physical interventions would often be reported in a first aid book, MHFAs weren’t always clear about what amounted to an intervention “and most organisations don’t have procedures on that.”
Simons said any mental health intervention at Thames Water is noted and fed to the occupational health staff, who then report trend data to him.
Narayanasamy said that organisations had to accept that they might never get the full picture of MHFAs’ contacts because some were so informal.
The CIPD’s Tony Vickers-Byrne asked if MHFA England was taking steps to address any of the concerns raised in the MENTOR study. Bonnar said the organisation was keen to work with others to develop more guidance on the role of MHFAs. It was talking to the Centre for Mental Health and seeking an academic partner to research the “half life” of MHFA training before skills faded. Refresher training courses were already planned. Another piece of research would cover the impact of MHFA on those supported by aiders.
Ian Goodhead, health, safety, environment and quality director of mega shed construction contractor Winvic, said his company had not jumped early into mental health support. He was concerned it would be seen as “just another health and safety initiative. We are facilitating it but not driving it. We need to get buy-in from other people.” He said there was pressure from clients to take action “but we want to do it for the right reason.”
Peter Brown, head of the health and work programme at the Health and Safety Executive (HSE), said the challenge for government was to take the work by the best employers to support good mental health “and to turn it into something simple that small employers can understand.”Kamile Stankute, parliamentary affairs officer at the Institute of Directors (IoD), noted that the majority of its 30,000 members led small businesses who would not have the resources to provide mental health support and that a member survey found almost 40% had been approached by staff with mental health issues but most had directed the enquirers to the National Health Service.
Tony Vickers-Byrne – chief adviser, HR practice, at the Chartered Institute of Personnel and Development (CIPD) noted that research suggested only 5% of wellbeing interventions were evaluated by employers.
Duncan Spencer said it was critical that employers were helped to do the right thing because international bodies such as the World Health Organization and International Labour Organization “recognise that there is a cliff edge facing many western countries in about 2030 or 2035 when their social security systems will be bankrupt because so many people will be elderly or off sick”.
These bodies see OSH professionals as being part of the solution to keeping people healthy and in work longer, said Spencer, and they will be exerting pressure through governments on to industry to develop effective systems to address mental ill health.
Karl Simons, chief health, safety and security officer at Thames Water - subject of a IOSH Magazine's December 2018 leader interview (bit.ly/2EqvnAA) – said that the week of the round table had seen the HSE update its guidance on workplace first aid to include mental health support advice and a framework from the Department for Work and Pensions (DWP) for voluntary reporting by employers on disability and mental health support in their organisations: “That is going to force boards and executive teams to say, ‘Right, what are we doing to support our employees?’.”
Fionuala Bonnar, chief operating officer at Mental Health First Aid England, said that her organisation wanted parity of esteem for mental health, giving it the same status as physical health. MHFA training was one of the tools to promote healthy conversations about the topic, “but it is just one of the tools”.
The experts were asked about the elements of a good mental health support system. Emma Mamo, head of workplace wellbeing at mental health charity Mind, said employers had to consider everything they did to support employees to stay well, how they minimised creating poor mental health and how they responded when employees were struggling, “be that emotional distress linked to a life event such as relationship breakdown or workplace pressures or a mental health condition.
“All the data we get back shows it comes down to the relationship people have with their managers,” she added. “How is a team being run and how does the manager support individuals if they are struggling?”
“Starting conversations” about mental health was critical to creating a supportive culture, said Stankute. “A lot of companies don’t even talk about it and that’s something you can do whatever the size of the organisation.”
“In terms of the overall organisational response I think it’s important not to see it as being just a health and safety approach,” said Robertson. “Because it’s also an equality, disability approach in many cases. It’s the whole spectrum of mental health we have to look at in policies.” He said a thorough approach would include policies on recruitment, sickness absence, stress management and bullying and harassment plus training for all staff in mental health awareness, like the short courses planned in the construction sector through Mates in Mind. He backed up Emma Mamo saying that line managers needed training and support to be confident to deal with issues.
“So it has a health and safety element and a personnel one; it’s the whole spectrum of the organisation.”
Vickers-Byrne said he had seen a healthy move recently away from blaming line managers for employees’ mental health stresses: “No line manager wants to ruin people’s health, but they lack the skills”. Managers needed the whole-organisation approach that Robertson described plus the back-up of trained staff such as MHFAs.
No sticking plaster
Dr Shaun Davis, group director of safety, health, wellbeing and sustainability at Royal Mail, introduced an element of Erik Hollnagel’s Safety II approach into the discussion (see p 29) asking why employers emphasise a 4% sickness absence rate, not learning from and modelling what keeps 96% of the workforce in attendance. “Are we using the right terminology to get what we want?” he asked. Or are we always using a reactive, negative paradigm.” He added he preferred the term “mental wellbeing” to mental health because it has fewer negative connotations.
Simons noted the British military uses the term “mental fitness” to give it parity with the physical fitness essential for service.
Sally Evans returned to the point that any single intervention was likely to be a “sticking plaster” on the problem, as some organisations had attempted with employee resilience training. She said employers should focus on remedying the systemic problems which undermined employees’ wellbeing.
Brown agreed with her and with Robertson that employers should consider a package of mental health support and said it was an opportunity for joint working between OSH and human resources professionals.
Drummond said that in the MENTOR research “one of the things we were surprised about was the lack of monitoring”. She said employers sometimes felt it was unethical or too sensitive to record information about mental health problems. But the data was essential for organisations to analyse mental ill health causes.
Spencer noted that IOSH’s research into return to work after mental health problems showed many people go off sick attributing their absence to something else, “so there is a question mark over the cleanliness of organisational data, because people would rather say they have back-ache than depression or anxiety”.
To evaluate an intervention organisations needed baseline data before, then to measure again after: “Too often it’s qualitative rather than quantitative measures”.
To help organisations looking for help to structure a mental health support programme IOSH has produced a set of benchmarking questions (www.iosh.co.uk/MHbenchmarking) which ask about their operational health provision, stress management practices and recovery controls, to identify gaps in current provision.
A separate information sheet, Mental Health First Aid: workplace considerations, (www.iosh.co.uk/MHFAconsiderations) is available for employers who have decided to offer mental health first aid as part of a wider programme.
The employers round the table were asked if they had revisited their other employment policies in the light of their drives to support better psychological health.
Evans said PwC had had a mental health programme since 2015, which now “permeates all our people processes. And we have the benefit of having approached this strategically so what we do around wellbeing and mental health is part of a global behaviour-change programme. It is linked to our culture and values work.”
Simons noted that few organisations investigated ill health instances and particularly those with a psychological aspect in the same way that they did accidents. “In safety we changed the word hazard, which means danger, into a positive [term]. We don’t blame line managers when an injury occurs, we say how can we prevent it happening again?” At Thames, he said, ill health cases led to changes to policies and practice.
The discussion turned to how small employers and not-for-profit bodies could be helped to support staff.
Robertson argued that it was easy to see mental health support as being more feasible for big than small firms. “Our experience is that the small ones, particularly the very small ones, are much better at dealing with it … What we need is simple advice, free advice.”
In response to a question from Karl Simons, Peter Brown said the HSE was looking to produce simpler guidance for employers, “looking at help with prevention at one end of the spectrum, what good support looks like and about healthy lifestyles”.
He recommended the HSE’s Talking Toolkit (bit.ly/2zHpKKh) developed for use in education, which helps structure conversations between line managers and staff about work stressors.
Vickers-Byrne added the CIPD and Mind had recently published a free guide to managing mental health for managers (bit.ly/2pTVpDP) and noted that his institute and Public Health England would publish a toolkit for employers, including micro-businesses, on choosing and evaluating mental health interventions.
Mamo said Mind also created a Mental Health Gateway to free workplace resources provided by other bodies (bit.ly/2A2vZck), which should help employers thinking, “Where do I start?”
Bang for buck
Drummond said that employers trying to decide what initiatives to fund should be reminded that interventions could be successful without being cost-effective.
“The bottom line is that these interventions will increase people’s knowledge and understanding of this area but there is no evidence that they are effective in the workplace. A lot of money is being spent when we aren’t sure what the bang for your buck is.”
Robertson argued that relieving the financial burden on the state of those who are out of the workforce with mental health problems “because of employers’ attitudes” would make interventions cost-effective in a wider perspective.
He argued that cost was not what puts employers off intervening, “it’s the fact they don’t know what to do”, especially in the case of serious psychological disorders, despite requirements in the Equality Act to make reasonable adjustments. “They think people can be a danger in the workplace or to themselves”.
Spencer added that IOSH’s research showed that to keep people with complex conditions at work employers needed internal co-operation between functions and collaboration with external agencies, “because there will probably be a mental health case worker working with that individual”, and that was challenging.
Simons said sharing case studies of organisations that had managed cases well would help others: “The 130 people who came forward last month [Thames Water employees with health problems] all have action plans with their managers and clinical teams helping.”
Spencer rounded up the discussion, thanking the participants for their contributions and summarised the themes as the language used by employers about mental health and the need for more positive emphasis. He noted the potentially bewildering choice of information and for better signposting. He said the participants had agreement that like any other employment issue, organisations needed policies and procedures for mental health issues and to assess need for interventions and their effectiveness – “there is work to be done on that”.
He said a better definition of the mental health first aider’s role and its limitations was needed. “There’s a lot to celebrate about that role and it is part of a more structured and wider approach”.