Alongside new occupational health (OH) referral procedures and stress risk assessments, Susan Gee has overseen the introduction of these initiatives at Yorkshire Water and its parent Kelda Group since 2013:
two-day courses, introduced in March, using materials from provider Mental Health First Aid England to train employees as mental health first aiders; 130 have so far taken the course
a depression self-help group run by an OH nurse for employees who have depression, or who have family members with the condition
a pilot to provide volunteer health trainers in the directorates to support health promotion initiatives
"We have a big workforce," says Susan Gee. "Most of those people come to work, do a good job and go home. But occasionally things go wrong and if you value people you want to be the sort of employer that is doing everything you can to support them. It's good business and it's the right thing to do."
Gee is occupational health manager at Yorkshire Water. Since her arrival in 2012 as wellbeing manager, she has overhauled OH provision for the company's staff and those of its parent, the Kelda Group, cutting sickness costs through quick intervention in absence cases and an innovative approach to predicting and managing stress.
The big workforce Gee refers to numbers 3,200. Around 1,000 work at the Buttershaw head office complex in Bradford where she and her team of four are based, but engineers are distributed all over Yorkshire's 12,000 km2 maintaining the water supply. It also has engineers in pockets from Aberdeen to Cornwall, and in Northern Ireland, in Kelda's other ventures.
She joined Yorkshire Water after 16 years managing OH at Bradford Council. Her new employer recognised that it had spent a lot of effort on safety management, she says, but had been reminded by Dame Carol Black's reports for government on the health of the working age population, issued in 2008 and 2011, that there was value in prioritising employee wellbeing and managing long-term sickness absence so that staff did not fall out of the workforce.
Body of evidence
The Capability and Conduct Policy -- covering sickness absence and OH referral -- that Gee inherited was "woolly", she says. It failed to direct managers clearly in how to manage ill-health absence: "It said things like 'at some point when people are off you will need to refer them to occupational health'. There were very few referrals because it didn't tell people when to refer."
She studied the company's accident and ill-health statistics, read reports of employee exit interviews and studied opinion survey results before deciding how the policy should be overhauled.
From her work at Bradford Council she knew it was critical to intervene early in sickness cases, ideally before a condition led to time off but certainly before days off ill stretched into months as the likelihood of a return to work faded.
"The psychology of people interacting with OH is interesting," she says. "From an employee point of view it can be seen as a covert disciplinary process that you are shuffled into. And where managers have well-established relationships they are nervous because they see it as 'doing something to' people that they know employees view negatively."
These beliefs are seldom articulated in organisations, she says, but are no less strong for that.
Managers who think they are doing an employee a favour by putting off referral are placing at risk the worker and the organisation, she says.
In 2012, there were 168 referrals to the two physicians and a nurse who fielded OH cases, a rate she describes as "abysmal".
Gee worked with her human resources colleagues to redraft the policy with clearer instructions for managers and earlier intervention to curb long-term absence.
The two most important new requirements, based on the evidence she had gathered, were:
referral of all stress and musculoskeletal disorder (MSD) cases to OH on the employee's first day of absence
referral of all other cases on the 14th day of absence.
The policy emphasised that, regardless of these thresholds, managers can refer employees at any time and employees can refer themselves, irrespective of whether the cause of pain or anxiety is work- or home-related.
(Gee notes that Yorkshire Water was paying for an outsourced employee assistance programme when she arrived and it had fielded only 22 enquiries in the previous year. She cancelled the contract on the basis that her OH service could better handle requests for help.)
If your manager is bearing down on you counselling is not appropriate, what you need is resolution
Another innovation was day-one referrals for accidents that necessitated time off work. This was instrumental in reducing the number that resulted in a seven-day absence, which would trigger a report under the Reporting of Injuries Diseases and Dangerous Occurrences Regulations (RIDDOR).
Managers might respond to an accident by investigating the cause, she says, but they seldom questioned whether time off was the best tonic for the victim. "So we wanted to get a change in culture, where alongside the investigation the manager is thinking 'is there a physiological problem that needs early treatment?'."
She adds that this approach works both ways because a swift functional capacity assessment will catch those cases when an employee overestimates their ability to carry on working after an injury or shock. "Often the employee doesn't want to let people down," she says, noting that staff who work remotely or are part of a rota "just want to get on with it, which can just lead to more sickness absence".
She talked early on to the company's recognised unions, the GMB, Unison and Unite, and says that, though they initially saw a risk that quicker diagnoses could result in more dismissals on the ground of capability should the company be unable to adapt work to fit an employee's condition, they also saw benefits. Once they understood the purpose of a robust policy was to ensure equality of treatment and consistency of approach they were, and remain, "massively supportive". "We explained to them the focus of occupational health was to retain employees.
"Operating a policy that is transparent and fair engages not just the employees' representatives but the workers themselves. We know from the research that organisational justice is high in generating employee engagement; people need a sense of fairness."
This is not a matter of ethics, she says, but of productivity: "What do we know about people who are engaged in their employment? They display a great deal of tertiary effort, and that is the first thing to go."
Not letting go
After the policy launch at the start of 2013, the OH staff backed it up in the spring with training sessions for every manager in the business covering the function of the OH service, and explained the reasons for the policy changes. Gee says: "We invited them in groups of 15 to 20 and HR talked about what sickness absence was costing us per month, and the legal risks of unfairly dismissing people if we were inconsistent. We tried to encourage them to understand that, apart from the need to respect the Equality Act, a good employer would want to explore adjustments to get people back to work."
As an aside, she observes a tendency in most businesses to see people whose performance is compromised by sickness or injury as almost broken, and that it takes effort to get managers to remember that the organisation prized that individual's abilities at recruitment. "If you were so sure when you employed them that they had value to add, unless there's evidence that they haven't done the job, you should be making every effort to retain them."
In cases where employees report stress or anxiety, a nurse adviser in the team will decide their best route to help at an initial assessment. Gee says this filtering process sometimes reveals that problems may be better dealt with in the teams, or by involving HR staff or union representatives.
"If your manager is bearing down on you counselling is not appropriate, what you need is resolution," she says. "If they are self-referrals we tell them we can help broach the subject with their manager but they have to give us permission. If it's a management referral we will write to the manager and say 'these are this person's perceptions, you need to do a stress risk assessment for the individual and the team'." See the five-step stress assessments in the box below.
For all other cases, Gee's team has a counsellor trained in cognitive behavioural therapy who covers the Buttershaw site and a network of contractors for the rest of the county and across the UK. They provide eye-movement desensitisation and reprocessing for post-traumatic stress disorder cases and a consultant psychiatrist is available to handle more complex mental health problems.
Five-step stress assessments
Yorkshire Water's Stress Policy explains to managers how to apply the Health and Safety Executive's five steps to risk assessment in their team stress risk assessments.
Step 1: Identify the hazards based on the team's tasks and workload.
Step 2: Decide who might be harmed and how, allowing for the fact that some jobs, such as customer-facing roles and those involving long shifts or long-distance travel, may have higher exposure to stressors.
Step 3: Evaluate the risk and take action, using information on team morale, turnover, productivity and absence as well as team feedback to make the assessment, categorising the risk as high, medium or low and using policies and management guidance in the Stress Policy to help decide controls.
Step 4: Record the findings to create a formal action plan for managing stressors.
Step 5: Review and revise the findings when necessary, either annually or when triggered by a significant change, such as restructuring, new processes or equipment or staff shortages.
A business case
Managers occasionally ask whether the counselling or physiotherapy services are duplicating NHS effort. "But if you consider the waiting times, you could have someone waiting six to 12 weeks before they even get considered for referral," she says. "So if it costs us just £500 to £600 to put someone through a course of physiotherapy and they aren't off work, the saving is simple to calculate."
At times, she says, the service's pragmatic approach leads it outside the policy's strict terms to organise treatment for employees' family members. In one recent case an employee's son was waiting for two years for a CAMS (children and adolescent mental health services) assessment on the NHS.
"It came to my attention because that person's work performance was starting to suffer," Gee says. "I referred the child to a child psychologist for a number of sessions that equated to what we would have spent on counselling the employee."
Gee's latest report on back, neck and shoulder pain referrals said that in the 12 months to May 2016, there were 430 referrals to the contracted physiotherapy service; 17% of patients were off work at the time of referral and 26% were on modified duties. Of the total, 95% were maintained in work or returned to work after treatment, saving an estimated 2,724 work days -- based on industry averages for MSD absence.
The new policy and the work of Gee's team to raise awareness of OH support led to a rapid increase in referrals. Between 2008 and 2012 they averaged 130 a year. In 2013 they rose to 291, then jumped to 926 in 2014 and to 1,102 last year. The unions now often refer members to her section directly, reflecting their confidence in the process.
She recognises that a referral rate approaching one-third of the workforce could be seen as a failure to control the hazards at source, but since the scheme is open to anyone with a health condition, whether it is caused or exacerbated by work or not, she says the proportion is not so remarkable: "It just mirrors modern life. This is about unmet need."
Apart from the hard metrics of days saved and early returners, Gee ensures all referrals are followed up with a satisfaction survey and reports that 96.6% of people who use the OH function say it was a positive experience, and almost 60% rate the service as excellent.
Since stress was one of the main sickness absence triggers, after launching the new Conduct and Capability Policy, Gee set to work on preventive work to try to reduce its causes.
She had previously developed a form of individual stress risk assessment after counselling hundreds of distressed teachers at Bradford Council during a massive reorganisation of the city's schools.
"The council was being taken to [employment] tribunals and I thought, we know these people, we recruited them and had access to them and yet we are in a situation where perfect strangers at a tribunal are sorting out months of mess in a couple of days and deciding clearly what should have happened and what's going to happen."
She introduced a policy at Yorkshire Water in which a referral or self-referral to OH triggers an individual stress risk assessment -- a form of early diagnostic tool that asks the employee about their perceived stressors. She says "we don't have to agree with them, but we have to acknowledge their perception" and how they believe the situation could be ameliorated. The next step is to look at what management can reasonably do to help and to draw up an action plan with the line manager or an HR representative.
But these reactive assessments would only ever affect a minority of workers who were already reporting stress symptoms. The introduction of separate team stress risk assessments stemmed from a chance meeting in early 2013 between Gee and John Hamilton, head of safety, health and wellbeing at Leeds Beckett University, who had already developed a group stress assessment model.
Hamilton's model is based on the Health and Safety Executive's (HSE) stress management standards, which prioritise six factors including work autonomy, manageable workload, work relationships and organisational support.
"The team looks at what can cause stress and what is in place to moderate that," Gee says, "and is that enough?"
Each factor is evaluated using the HSE's five-step method risk assessment method.
If a team feels that the stressors members face cannot be managed at their level, they have the option of escalating the issue up the management line. But most problems stem from a lack of communication, she notes, and the stress assessment process often goes some way towards improving team dialogue and communication from managers.
OH staff give a presentation to teams, jointly with union representatives, before they embark on the risk assessment to explain its purpose and that stress is a natural byproduct of some work activity that can be managed to avoid harm to individuals.
"We weren't going out saying 'we are going to identify all stress, then you'll have to get rid of it'. The point was to light up all the room and make plans to deal with it, so far as is reasonably practicable, to avoid crises."
The assessment is also preceded by a half day's training for the team manager.
In some areas of the business all the teams have been through the mandatory training and risk assessment process, starting with the senior leaders. In others the programme is still being rolled out more than two years after it started. Gee says operational needs in years marked by heavy flooding have contributed to slowing the process, "but there has been no resistance".
The roll-out in each of the eight directorates is controlled by a local health and wellbeing group. These groups, set up in 2014, each send a member to a central Strategic Wellbeing Group, chaired by a director, which ensures consistency in site standards for matters such as risk assessments and health surveillance across the group.
The team assessments have raised the perception of stress risk among employees, she says, but they also provide valuable management information. Employees' frustrations reveal inefficiencies and process problems: "You are getting a snapshot of that particular bit of the organisation."
Though Gee has introduced some of the "softer" initiatives associated with the term wellbeing (see above), most of her work, which started when she still had the title wellbeing manager, was more traditionally associated with core health management. She sees the two as interdependent. "Health and safety is the nut and wellbeing is the shell around it," she says. "Wellbeing is a natural byproduct of good health and safety."
Sickness absence averaged 3.79 days per employee when she arrived in 2012. After the new referral system and Capability and Conduct Policy were launched it dipped to around 2.6. It has fluctuated since -- the average was 3.08 in 2015 -- but always below the previous total, and Yorkshire Water calculated a total saving of £800,000 in sick pay and cover over two years.
"This isn't job done, it isn't perfect," she says of the OH initiatives, "but we have moved from that 19th century view that your work is your work and you keep your problems to yourself.