UK and US: Workplace tale of two healthcare systems

Countries take different approaches but realise that healthier workplaces make sense
David Cameron had lined up legislation to make overseas visitors pay for NHS treatment © Getty

Listen to this article

00:00
00:00

When Simon Stevens was working in the US, his employer United Healthcare provided incentives which prodded him to lose three stone in weight — some 42lb or about 19kg — through an improved diet and more exercise. Now in his role as chief executive of NHS England, he hopes to prompt a similar result for others in the UK.

“I’m a personal example of how workplace health can be effective,” he says. “There’s a lot of evidence from a lot of employers that these things can make big shifts across the workforce. If I had to write a book, the title would simply be ‘eat less rubbish’.”

Stevens has been stepping up his activities in two different fields: persuading employers and their staff to take more responsibility for their health and ease the burden on the NHS; secondly, to do far better by the NHS’ own workforce. With more than 1.3m staff, the NHS is the UK’s largest employer.

“The health and working habits of people aged 18 to retirement have an enormous impact on their wellbeing at that point in their lives, and shapes whether they will have a healthy retirement,” he says. “We often think of the NHS as particularly looking after older, frail people but the reality is about 40 per cent of our budget, £40bn a year, is spent looking after illness for working age adults.

“Because of our tax-based NHS, we rightly don’t burden employers with those costs directly. But one of the flipsides is sometimes we’ve neglected the workplace as a setting for health improvement. A lot of progressive employers have clocked the fact they have done many things that are good for their business and their staff to help prevent illness that would otherwise make its way to the NHS.”

He stresses that he is not arguing for a US-style private health insurance system in the UK. But the fact that costs in the US are so high and continue to increase, means the healthcare costs of workers have become a matter looked at not just by a company’s human resource director but also are “a top pressure for the chief financial officer to review each year”.

UK employers could draw on more such innovation from abroad. He adds: “The whole area of ‘behavioural economics meets the psychology of health’ is fertile territory: what individuals do, how their environment is structured — the canteen, the ability to run at lunchtime, the physical stresses and strains of manual work, the ergonomics of the workplace.”

Simon Stevens, chief executive of NHS England © Charlie Bibby

Stevens points to three important areas where employers could lessen the burden of ill health in the workplace. The first is musculoskeletal conditions including back injuries, often linked to poor posture and excessive desk-bound work, as well as sprain-inducing manual jobs.

The second is obesity and diet. “The biggest cause of the UK’s avoidable ill health has become poor diet, relegating smoking to second place,” he says. He argues that working environments themselves encourage poor lifestyle habits and diets, contributing to conditions including heart disease and Type 2 diabetes.

The third area is stress, anxiety, depression and other common mental health disorders. There is growing awareness of this, he says, “and the need for positive mental health interventions, not just in professional service firms but in blue collar and other sectors”.

Uncertainty remains about how to tackle the problems and how to support and motivate employers — especially smaller ones with more limited resources. That is why he has called for tax incentives such as a national insurance rebate.

“Particularly for small and medium-sized enterprises, there might be a case for looking at whether incentives would be useful, given they often lack the human resource infrastructure,” he says. “If we can prove the case through programmes that employers are putting in place that they help their businesses and have a wider benefit for the NHS, there is a strong case for the Treasury.”

He sees scope for the NHS to draw on its own expertise to advise employers and to acknowledge good practices. He could envisage, he says, the NHS providing an official standard for healthy workplaces “doing the full battery of interventions shown to be effective”.

Stevens concedes that the NHS must still do more to improve its own reputation and working practices. Public Health England, a government body, estimates the cost of staff absence to the health service because of poor health is £2.4bn a year. Staff surveys highlight complaints about stress and being bullied.

The NHS has not always had a very good track record in looking after its own staff’s health, he admits. “At a time when we want to retain our highly qualified staff to deal with the pressures,” he says, “we have a strong economic imperative to get this right.”

Within the NHS, he is creating what he describes as “the world’s largest employee health incentive programme”, at a cost of £450m. It aims to combat employee stress, provide physiotherapy, push for more employees to have flu vaccinations and reduce staff obesity.

The latter goal includes plans for a “sugar tax” from next April to raise the price of sugary drinks in NHS staff canteens and hospital shops, stopping advertising, and in some cases banning the sale of food and drink high in sugar, salt and fat.

President Obama’s Affordable Care Act encourages companies to improve staff health © Bloomberg

Healthier and lower cost alternatives are to be offered in staff canteens. “We kicked out cigarettes in hospital shops and now we are acting to tackle the obesogenic environment.”

Other measures the NHS has taken include the appointment of a board-level director and senior clinician to promote workplace health programmes. Training for line managers concentrates on tackling the stress and other mental pressures experienced by staff.

What is Stevens doing to maintain his own health? “Rather than drive or take taxis around London, I tend to walk to the tube or bus stop. These little changes mean you can quite easily add in 30 minutes walking a day.”

Turning round the health of the general UK workplace will not be easy. Beginning with the NHS — a case of ‘physician heal thyself’ — is a step in the right direction.


Earlier this year, Johnson & Johnson issued a challenge to its employees to walk as many steps as they could in 30 days. Over 35,000 signed up, using a mobile app to create teams and track their progress.

Peter Fasolo, executive vice-president and chief human resources officer, says the participation of nearly 30 per cent of its employees is evidence of the culture the healthcare and consumer company has sought to foster for much of the 120 years since it was founded. In the mid-1970s, the $70bn company became one of the first in the US to institute a wellness programme, which has evolved over the years into one of the country’s most innovative, including classic elements like fitness centres and health screenings but mixing in modern twists like wearable activity trackers and a focus on mindfulness.

“We know that we need to make really strong investments in prevention and sustaining a very healthy and productive and highly engaged workforce in health and wellness,” he says. “It makes good sense to invest behind your employees, but it also makes really good business sense.”

Wellness programmes have proliferated in the decades since Johnson & Johnson first implemented one, as employers seek to boost productivity, lower absenteeism and control healthcare costs. President Barack Obama’s signature healthcare law — “Obamacare”, or the Affordable Care Act — contains provisions that encourage companies to offer such programmes, and there has been a significant increase over the past few years as the act has been implemented, according to analysts. They evolved, like Johnson & Johnson’s, from a primarily one-size-fits-all, top-down approach (a company for example telling employees they should try to lose weight or stop smoking) into more-tailored and holistic programmes that attempt to address individuals on a local level.

Fasolo points to data backing up Johnson & Johnson’s investment. For every dollar spent on wellness and health, the company recoups close to $4 in lower absenteeism and increased productivity, while employees’ triglyceride, body-mass index, cholesterol, activity and stress levels “blow away the [national] benchmarks year after year”.

© Getty

But despite their seeming ubiquity firm data showing the benefits of wellness programmes are surprisingly scant. “There’s not a lot of evidence that workplace wellness programmes actually reduce healthcare costs or improve health,” says Katherine Baicker, professor of health economics at Harvard University’s TH Chan School of Public Health. This is partly because the type of employee who participates in a walking club or goes to the gym is “very different from those that don’t”, making it difficult to test wether the walking club improved health or the people who join walking clubs simply lead healthier lives.

But employers may also offer such programmes “to make the job more appealing or just because employees like having those programmes”, she says.

That is the main reason employees at Zappos, the online shoe store, can earn points for health-related activities — from exercising to training for a marathon to going to the eye doctor — that they can redeem for sporting goods and gift cards, says Kelly Maher, the company’s wellness co-ordinator.

“We’ve always had an employee-first mentality here. It wasn’t necessarily to drive down claims costs or to get a return on investment, it was something we knew was important for our employees,” he says. “We want them to be healthy and we want them to be happy.”

The offerings started off as mostly fitness based. But over the past year or so, Zappos has begun to focus on other aspects of its employees’ lives, including their mental health — with an on-site counsellor — and financial needs.

They are part of a trend that has seen employers take a more holistic approach to their employees’ wellbeing. Paul Coppola heads the development and implementation of the wellness programmes that insurance company Aetna sells to its clients. He uses that word “holistic” a lot when describing both what Aetna offers its employees and the products it provides for its customers.

“Our focus is really holistic when we think about wellness and focuses on individuals,” he says. “Individuals’ physical wellbeing, emotional wellbeing, mental wellbeing, financial wellbeing and social wellbeing.”

A big part of the shift toward that approach is an emphasis on mindfulness. “We find a lot of strong success when we focus on stress, because it’s often an underlying factor in people’s health — when an individual is dealing with being overweight, it’s not just that they’re struggling with weight,” he says. “We’re trying to go deeper. That often goes to stress, a big cause of depression, which causes people to become isolated and a lot of times weight is a product of that.”

Historically, wellness programmes were “very directive, very focused on people telling other people what they needed to do”, he says. Now the focus is on individual needs.

Employers cannot expect to see results overnight. The benefits of a wellness programme can only be seen over the course of years, Coppola argues.

Fasolo says it is the longevity and depth of Johnson & Johnson’s commitment to its wellness programmes that have made them successful for both the company’s employees and bottom line.

“You have to be all in with your employees,” he says. “This can’t be a short-term fix, it can’t be a cost play . . . we’re going to save money — if you go in with that mentality, you will fail. You have to be all in on a long-term investment.”

Copyright The Financial Times Limited 2017. All rights reserved. You may share using our article tools. Please don't copy articles from FT.com and redistribute by email or post to the web.