Health and Wellbeing Board Development Masterclass Webinar

Health and Wellbeing Board Development Masterclass Webinar



good afternoon everyone and welcome to our board development webinar about creating a culture to support improving health and well-being i'm louise Pratt from the project lead for health and well-being at NHS England amenities improvement and I'll be your emcee for the afternoon collecting your questions as we go along and asking them at the end on your behalf we have two fabulous speakers for you today and support the improving health and well-being program at NHS England NHS improvement theme Carol black and dr. Paul Litchfield I just got some housekeeping to run through before we kick off so questions on this platform you you can type in questions and I'll be monitoring those as we go along so to submit a question click on the question button at the bottom of your screen please do submit questions as you think of them and we'll we'll be answering those at the end if you're not if we're not able to answer all questions in the webinar and we'll also be attempting to do that afterwards in a written format now you'll be able to hear us hopefully we won't be able to hear you at this time but if your sound drops out at any point please try refreshing your browser window or switching web browsers for other technical issues a few notifies for submitting a question we've also got colleagues in the room who can be providing technical support so please you know that any issues drop those through by that question function in terms of future viewing and the audio and slides for this webinar are being recorded and will be available to view again on the same link that you've accessed this webinar within 48 hours so you'll receive an email notifying you once the recordings ready and the slide deck will be accessible in the resources tab and in due course we do intend to publish this on our resources website finally at the end of the webinar we've got a feedback survey so that's a quick survey at the end will pop up once we've finished speaking and you'll be able to submit your feedback which we'd really value it really helped us make sure that we're providing a support that you need going forward so without further ado these are speakers just going to hand over to thank our back good afternoon it's my great pleasure to be sharing this webinar with Paul Litchfield I'm going to start by talking about the development of health and well-being through the eyes of NHS England an NHS improvement and this really goes back on the next the last ten years so if we can I thought we'd just remind ourselves of Steve Almond because in a way he said it all his recommendations are just almost perfect and as you'll see there recommendations that we've tried to put into the framework which we've been developing so I'd like us to bear this in mind as we go through the next are there was indeed an NHS systems leader summit in 2013 and the leaders were all very keen they all committed to do things but I think if I'm being honest I would have to say it didn't percolate down to the next the next level all those intentions were very good but I do want to mark out that in 2014 when Simon Stephens became the CEO of the NHS he said quite clearly that NHS employees will need to be healthy mentally and physically and have good health well-being and be fully engaged and of course that was said earlier by Steve Borman things really started to develop when in October of 2014 we decided that we would try and develop proposals and offer for the NHS at that time it was really important to stress implementing nice guidance there's some extremely good nice guidance on workplaces especially for mental health promote interventions and it interesting at that particular time the work case well-being charter and the Global Corporate Challenge were popular and were therefore supported strengthening Oh H which is still a theme that runs through all we do and that time we were working very closely with the Faculty of occupational medicine and Simon had a very great interest and determination that food should be much healthier in our hospitals and NHS facilities this is what the summit in December 2014 are committed to and at that time we created a group and around the table were public private and academics and third sector members and the whole thing was to a devise a way forward we learnt a great deal from our private sector colleagues there were some very very good examples of exemplary practice but we also learned a great deal from the third sector our academic partners were useful and we have made good public sector organisations so that group that rather informal group became the advisory board I just wanted to go back and remind us again of the nice guidance and to ask you to think about how that guidance is very much reflected in what Steve Borman said early on and we're really building up and I know Paul will continue along this theme with the importance of leadership line managers board engagement and indeed the organisation of work and nice at that time thought it was very important to provide a business case and economic modelling in order to strengthen the role of the line manager and indeed to persuade our finance directors that this was worth investing in our work started with 15 trusts and we thought we would ask them some questions and I've listed those questions here and you can see that they were about what they offer was the cost and scale of it importantly how much participation there is in the program and we were interested in whether there was any incentivization because certainly in some parts of the private sector incentivization was happening how do you evaluate it or was a tricky problem and indeed what was the outcome this is just a summary of some of our results most trusts consulted stars they admitted there were many many initiatives but evaluation was scanty therefore hard to prioritize many of those initiatives were such things as gym membership a Pilates class maybe a Zumba class fresh fruit improved food in the cafeteria there was very little CEO involvement it was rarely mentioned so leadership was absent there was little discussion board level involvement although we knew that there were one or two trusts where a non-executive member of the board had a health and well-being responsibilities and in those trusts that had been seen to be a very useful arm intervention there was little direct focus online manager training so I think the three things that we would think to be of great importance was missing in most of the trust set that we questioned at that time most offered healthy food choices and fitness classes participation patchy as we so often see but very usefully most trusts targeting mental health and MSDS which we would still today consider to be two of our most important challenges incentives very little evidence of incentives being used within the NHS and evaluation was mostly the secondary effects and very importantly there was often an inadequate baseline people didn't really know their data and they didn't have that baseline from which to build and to design their interventions in September of 2015 Simon Stevin said there was going to be major drive to improve the health and well-being of NHS staff and he said frankly the NHS needs to put its own house in order and you can see of the 5 million initiatives there were three pillars the one that we be most engaged with was the drive for improved NHS staff health and now I'm really shortening a whole a whole deal of work that we've done since 2014 we've gone through many iterations to develop our framework but we wanted a practical tool to support the health and well-being of NHS staff it's been developed over this time by a healthy workforce team in NHS England with an expert advisory board and Paul and I are both members of that board we've had great collaboration from NHS Trust we've had NHS demonstrator sites where we've Co designed and tested the content so it has gone through a long development process and it was an iterative process so we have talked it sets out of 40 tellement covering as you can see they're enablers and health interventions particularly important mental health giving case studies and guidance on implementation and of course describing good practice a diagnostic tool to benchmark quickly on each element with three basic questions can also be found in in the framework and this can be found on NHS employers and NHS I websites I'm coming back and I think you will hear this is a repeated message to the fact that we considered there were some essential and enablers and they were leadership broad engagement and manager capability of course they're much more difficult to do than the fresh fruit the bicycle schemes the gym membership but they're essential and I think we would say that if you don't take on the more difficult agenda of leadership board and managers then when you put in the other interventions they're a bit like sticking-plaster and they're certainly not going to have a long-term effect so here is our framework I won't delay on on the component parts of it but you can see these organisational enablers I do just want to bring out the data on this must be data-driven and I'll come back to that in my second part of my talk and the health interventions mirroring the challenges that we find in almost all workplaces of mental health and musculoskeletal health our program at the moment at 70 C tasks there and you could see the combination of the trust that that are within the programme where we're really trying to roll this out and and and learn from from this program so that we can make appropriate adjustments but all trusts have access to the framework to thematic interventions and case studies and and resources that they can access so that really is a very brief canter through the way we've developed the framework and I think we could say there that we do have leadership engagement for what we've been doing but I now want to pick up on that data point I'd like to look now to collection of health and well-being data in the workplace on its data that would have been collected by Britain's healthiest workplace survey over the last five years and to try and get an a sense of how such data can help us focus on our interventions to improve health and well-being but also as in this slide productivity productivity in the NHS in my mind is really about patient care and the quality of patient care but many things contribute to that and I want as not to forget that although sickness absence is important presenteeism is the most significant component of productivity loss so this is Britain's healthiest workplace and your survey it has an advisory board technology from the University of Cambridge and around Europe reported annually in the financial times many NHS trusts and I did just check yesterday about exactly how many and it's 41 but four hundred and thirty organizations 150 thousand employee respondent since its inception some five years ago as some of you may well know it the way it said it's developed and delivered is first of all inputs the inputs from the management of the organisation and inputs from employees of course on a voluntary basis the outputs then are an organizational health report a very comprehensive one to the institution and and to its executives an individual and of course entirely private health report to each employee who participates with suggestions for improvement and then a visit to the workplace to help that organization develop its plan to improve what the data has has told of them these are just one or two high-level messages and I've just chosen a few of the results this is a cross sectional analysis on 98,000 distinct employees over three years over a three-year period the funder I should have said of Britain's healthiest workplace is vitality on what I might call a virtual educational a really important message from this slide I clearly the size of these circles and in the bottom you can see the contribution of mental well-being risks to productivity loss and you can see depression at 19.1 days bullying some 5.9 days financial pressure is also an important factor and then of course there are lifestyle risks and clinical risks but it is that mental well-being which contributes so much to productivity loss in our organizations workplace stress this is now on an taken just I took the 2017 results mental well-being I think these results will come as no surprise to you but 54% of employees having at least one dimension of workplace stress was 27% having to or roar and so often the mental health and well-being of employees is linked back to the leadership in the organization the broader engagement and the line manager capability I said financial concerns are were important and here you just see some of the figures again from the 2017 our annual survey I am sure the CEO of Wigan hospital will not mind me saying that andrew said to me that when they took part in this particular survey he had never expected that financial concerns would loom so large in his in his results he was as he put it shocked by the figures he immediately did something about it and went into the competition the next year and reported a considerable improvement and financial concerns we forget that financial concerns are of great importance and they are of course related to our mental health depression is is much higher in those individuals with lots of financial concerns and then thinking about our musculoskeletal challenges this is the 2018 survey this is just back pain but it's the correlations that I think are interesting and important correlation with productivity loss a correlation with physical inactivity and in this particular analysis with nutrition obesity and smoking profiles and a correlation again with mental health so musculoskeletal and mental health should be considered together and not with isolated features I'm afraid this may not project too well but let me take you just through the really important message from this slide IRC analyst to look for me at the information we had on business outcomes mental health outcomes and cultural outcomes depending on your board meeting frequency so less than annually annually twice per year or more frequently and really the messages in the colors red is is bad worse Green is better good and you're yella is in the middle and you can see from there twice yearly reporting to the board in this particular survey had an influence on business outcomes mental health and culture and very finally the main messages from our 2008 UK cohort on this time 26,000 employees 129 organizations I just want highlight this factor that one third of productivity loss in this 2018 cohort was related to work stress and lifestyle choices and an average productivity Kilis calculated to be 81 billion this is information that has been given to me by a psychologist in Switzerland and I've just asked to borrow two of his slides has he been doing a lot of work with middle sized and smaller sized organizations on the health both physical and mental of the line manager and how that might affect or interact with the health of the people who reported are too on to the line manager so 2017 survey about 1,400 managers and it was either I've never had a health problem I've had a physical problem psychological problem or I've had both a physical and psychological problem and we need to take home message is that healthy managers appear to have healthier employees and if you have the combination of physical and mental ill health as a manager then that of course is the worst combination it may of course be a sort of not only just the effect of the health of the line manager on the employees that may be an effect the other way but I think what it is telling us is that healthy managers are a very good thing and therefore one should support the health and well-being of one's line manager so very finally I think what I want to conclude by saying are we need a good workplace and a good workplace we'll have good mental health and well-being and I just listed there some of the things I think to be extremely important please don't miss it just do the sticking plasters and I'm going to hand over to Paul who will go further into this aspect as of work thanks Mary Carol good afternoon everybody I was reflecting that it's over 20 years now since I edited a book called health of the healthcare worker in which I made the point that it's often the Cobblers children who are the worst shot and I reflected that it was rather odd that the health of the healthcare workforce should be at that time so poor I'm not sure things have improved all that much and indeed some would argue that things have got worse certainly when I go and speak to colleagues down the road in Whitehall and Westminster in the rare moments they have to think about things other than brakes it probably the top thing on their mind is the productivity issue which Carol is already referred to in the UK and we have a paradox in that employment rates in this country are almost set and historical high but our productivity over the last 10 years has hardly shifted at all and we're falling behind many of our key competitors and there are various explanations for that various attempts to explain it but a common explanation is that yes there is plenty of work but a lot of it is not good work and what we see is that work all too often is making people unhappy making them unwell and that's especially so in the public sector and the healthcare sector and as Carol said presenteeism is a bigger issue than absenteeism but when you put the two together you can see that health care is towards the top end which unfortunate along end of the spectrum in terms of the number of people off or at work suffering with health problems and that stress in the public sector in the healthcare in particular is higher than in any other sector and when one looks at that in financial terms then the cost within healthcare are higher than anywhere else in the public sector so it's undoubtedly an issue from a financial perspective I think even more worrying is that the healthcare workforce is voting with its feet if one looks at nursing then almost a third of people who start nurse training do not end up working in the healthcare sector either in the secondary care or primary care two-thirds do but almost a third just go and work elsewhere if we look at junior doctors of those who complete foundation training ten years ago over 80% of those would have gone on straight into higher specialist training these days it's down at 37% I think though the important thing is the other side of that bar chart the yellows and the oranges because almost 45% of people are not even working in the health service some are going abroad some are taking a break from work and a significant number which is the yellow bit of the chart there are doing other jobs other than medicine now we might get some of those people back into health care and some of those people back into the NHS but we're going to end up losing a lot and that strikes me as a huge waste of expensively trained resource work is a major driver of people's well-being and there are various ways of thinking about that but one of the ways I find most useful is to think about the drivers of well-being and there are five key elements to that four of those what a philosopher would term the hedonic elements in other words that's the the attribute in human nature that you try to maximize the good things and minimize the bad things and then the fifth element is the eudaimonic element which a philosopher by which a philosopher means that as human beings we need to feel that we have meaning in our lives a sense of purpose and when you look at those hedonic those tangible elements if you like health is an important one but there are other things to security relationships environment are all important and it's in security it's not just physical security its financial security and a lot of works been done on that in recent years relationships yes relationships in work are important with so relationships outside of work and then the environment yes it's the physical environment but it's also the culture and I think critically the systems that we require are people to work to all of those things together with purpose are what drive well-being and we need to think of all of those if we're going to try and improve the well-being of our people most people get the link between health and well-being and I don't want to underplay it because if you look do regression analysis health is actually the strongest driver of well-being but particularly to this audience I'm not going to later the point of course it's physical health as well as mental health and it's about getting healthy staying healthy and recovering health if you become ill and you can get loads of apps help will help you do it these days but just to say a word about those other elements so the environment we need to think about the physical environment that our people are working in things like air quality the design of building the amount of daylight the type of lighting that we give our people to work under all have an impact on their well-being yet too often we neglect those things relationships if we take divorce as a surrogate for breakdown in personal relationships the peak time for divorce is between the ages of 40 and 45 people in that age group are usually our most critical people there are most experienced nurses there are new consultants that are going to be delivering services for us for the next 20 years they're the people who really make the organization they're probably the people who are going to be the chief executives in five years time they're critical and yet we tend to neglect what's going on in their lives and there are things that we can do in terms of giving them support too often we don't do it purpose in health care we're fortunate most of us have a strong sense of purpose about what we do we feel that it is important for society and then security financial well-being is so important the figures shown there from a study that neighbor did a few years ago frightened me in the almost two thirds of people are this is people in work are borrowing money to put food on the table to pay their bills this isn't about going on holiday abroad this is about the basic needs in life two-thirds of people are borrowing money for that a third used credit cards to fund that debt and 8% use payday lenders which is almost a guarantee that they're going to get into a cycle of unpayable debt and there are things that we can do in work that will help with that I won't labor it might come up in questions but in Beattie we set up a salary finance scheme which was hugely successful in terms of helping people stay out and get out of debt far too often when we think about well-being we focus on the individual and we don't think enough about the organization both are important we have to think about both and if you look at the right the diagram on the right-hand side of the screen there those are the six risk factor elements that the HSA is produced in their management standards so the six things that contribute to whether people feel stressed or not there are management standards it's a legal responsibility that we manage those and yet too often that's honored in the breach we don't think about it when we are creating jobs when we're managing our people but we know good work promotes well-being we know that bad work destroys well-being and Danny Kahneman who is a Nobel prize-winning a psychologist did a bit of work 15 years ago now and the quote there individuals find meeting their line manager the loose Pleasant moment of the day I find unutterably depressing and as a line manager as I was until very recently I found very humbling that that might apply to me and I think it's something we should all reflect upon because we know what good work looks like there's plenty of research on that there's plenty of evidence this is from a publication that we put out from the what works center for wellbeing about 18 months ago now and the 11 elements there are the components of what a good job looks like the things that will make people feel better about themselves made them feel motivated and I'm not going to read them all out but it's a mix of things about the way that you organize that the work and the way that you support people in doing that work and also with the other things going on in their lives so it's about designing jobs properly it's about thinking about the design of the organization which is much more than spans and layers for Asia our colleagues on the call it's about culture and as Carol rightly emphasized it's about leadership we know that if you do do these things you do drive up the well-being of your workforce so not just deal with the people who have stick with sticking plasters or whatever it might be but focus on the whole of the workforce and drive up their levels of well-being it has real business benefits so there's good experimental evidence that I the one I like best probably comes from Andrew Wolf's world at Warwick University where in laboratory experiments he showed that you can get a ten to fifteen percent increase in productivity by raising people's well-being similarly there's evidence in relation to individual workers from the workplace about a similar level of improvement in service quality looking at organizations again there's evidence that's been coming out over the last few years show that you get higher levels of customer loyalty those of you with a commercial background will recognize the term Net Promoter Score which is a standard way of estimating what your business is going to do in the future increase productivity increase profitability and reduce staff turnover that is all published element evidence and was brought together in a publication that we put out in February this year the global happiness and well-being policy report so go to chapter 5 there if you want to read about it in detail but the evidence is there but of course none of that relates to the National Health Service and we know that we are very different well maybe we're not because again we did an evidence review in the what works center about 18 months ago which was looking specifically at people management practices within the National Health Service and as you can see from the bar chart those organizations that ranked well in terms of those management practices that I spoke about earlier they had significantly higher levels of job satisfaction worker engagement their absence levels were lower patient satisfaction was higher all of those with significant differences mortality was also lower when levels of well-being were higher now that's not significant but looking at those bars I think that trend tells you something even if it isn't statistically significant so this does matter it does apply to the NHS so how are we going to make it all happen what we need to do is persuade people that this is the right way to go and too often we just focus on the chief executive we need to engage everybody in the organization of course the chief exec and the senior management team are critical in terms of giving sponsorship and leadership but specialist functions very important to particularly our colleagues in human resources there the people are going to be implementing a lot of this stuff they have to be on board middle managers can either be a huge enabler or an amazing barrier are I often say they translate chaos they take the bright ideas that senior management come up with and have to translate them into something that's going to work for the people on the front line line managers we know from doodles of evidence that line managers have the biggest influence on their staff they're the people that we need to really get the message true work of representatives and of course ultimately individual employees the arguments we use for those groups about why it's important to engage with this will differ but they have to be coherent they have to be complementary and that means we have to have a mental model from what we're doing and a public health model works extremely well in this area so primary engagement primary prevention secondary intervention when things are starting to go wrong and tertiary resolution for when people have become ill those are the three elements and what you typically find is that as an organization improves in maturity they go upstream and spend more time and resources on primary prevention than sorting problems out after they've gone wrong but we need to turn that mental model into something which is tangible and one practice which I on a number of others have found very helpful over the years is to create a nine box grid and to think about those three primary secondary tertiary elements think about education and training assessment and practical support and just write in the Box what are you doing in each of those areas and if you do that it will reveal to you where you've got gaps where you've got duplication and allows you to demonstrate that you are offering something which is coherent when I started on this stuff 25 years ago there wasn't a lot going on we had to invent stuff we had to design stuff we had to build it for ourselves and there was some joy in that an awful lot more frustration but you're not in that position you don't have to reinvent the wheel there's an awful lot of guidance out there the NHS framework health and well-being framework gives you something to work to already it's evidence-based its sound you can trust it there it's supported by wealth of resources which are specific to the NHS of course there's stuff outside the NHS that you can use if you want to but even within this eco sphere there's plenty of guidance in there so please don't waste time and energy in reinventing things simply because you feel it hasn't been invented in your shop so to round off we know that if we promote health and well-being in the workplace we're going to create higher levels of resilience that's not just resilience for the people who work in our organizations its resilience of the organization's themselves and what's more particularly for the biggest employer in the UK it's contributing to a resilient society a resilient UK that's a worthwhile thing to do and I would urge everybody to give it a go thank you great thank you very much thank our doctor Paul so over to you folks we've had a couple of questions coming through during methylome I'm sure there's a lot of reflection messages and as we've gotten information in there so I'm going to kick off with some of these questions so first off the bat what practical first step because of all it takes to improve the health and well-being and they're all sensation I think a very practical step is to take one of the non execs and there will be several non exact on the board and give them a task and their task would be to know about their health and well-being of the employees in the organization to get to know the people who are trying to deliver it and and of course to work with the HR department and then to take to the board on it seems as if a biannual report in our business healthiest workplace survey was a good frequency but to really make sure just as much as finances report it to the board health and well-being is and that things happen as a result of that and that really means you've got an independent I do respect it it's no use having an executive member of the board we need independence we need that person to start to get engaged in health and well-being of the employees and very practical example is a the NHS trust in York actually several years ago did this and they noted you can't say it it's the absolute reason for it but after they had had this for two years they noticed a reduction in their sickness absence and staff turnover an engagement so I think that's a very practical thing they can do here and now so I would agree entirely with that if it was me as non-exec that carol has been talking about then I'd want to start with having a measure I could trust a former chief exec of mine said what matters gets measured and so make sure that in your trust there is a simple and I stress simple measure of well-being and I would commend to you the Office for National Statistics work which is hugely robust in terms of the quality of the evidence that underpins it but there are four simple questions that give you a good indication of whether people feel that their well-being is good or not and if you only have to go for one go for the life satisfaction question which is overall how satisfied are you with your life these days that one question and track it over time and then to support that I would want to say to my people within the trust right let's focus on no more than three things they don't have related to those drivers I think one of the issues we have is that there is so much out there at the moment that you can get lost in trying to do too many too many things focus on a vital few as I say no more than three things within those five domains that you're going to make your priority for the next given time period and see then how you do against those and the impact that they're having on well-being that that's the way I would address approaching great thank you guys okay another question that we've had through and I get you know a follow on from that really related so how can four members act as role models in the health and well-being space stop um so they can do the tried and tested rather tacky things like losing weight I've done that one home being seemed to take exercise all those things frankly they're a bit simplistic I think the biggest issue is around culture and I think the shadow of the leader is greatest when it comes to culture so being genuine about treating people with humanity and that's recognizing when people are struggling and helping them rather than destroying them it's about treating people with civility and kindness and I think if a leader does that then you will be amazed how quickly that message goes through the organization even simple things like as you go around saying thank you a genuine thank you not the McDonald's coached type of thank you and nothing else we're done but don't sell them in the hospital for you so those are my thoughts I do be very quick and say in a genuine participation in in activities that are within the trust so you're visible and seem to be supportive and as Paul said not just I got to be here because kind of that's what I'm supposed to be but that's genuine interest in in health and well-being and it shines through I mean you could see it you know when you go into an organization and we visited a quite a lot of trust you sense where this is a place where this is happening and thank you I think you touched on this a bit earlier and perhaps can expand on it a little bit more how to board members health organizations to balance the need for operational delivery with that important message of looking after their people so they are not an either/or the one supports the other if you support your people treat them with humanity create a working environment where people are looking forward to coming to work then they will be more productive and things like your sickness absence rate things like the number of job vacancies that you have will all improve as a consequence of that instead of focusing on those outcomes and neglecting the root causes if we think about the root causes we will actually influence the outcomes so I don't see them as being contradictory at all I see them as being supportive of each other I just would endorse entirely what Paul has said but just to say the number of times I've met with CEOs and although they think this is quite a good idea we'll say well I just don't have time to do that Caracas I'm so busy running the organization without them understanding or seeing as Paul says that if you don't do the looking after your workforce and doing it well and and and really genuinely then by the way your operations are going to suffer it can't be an either-or they're absolutely interdependent and I think that's something we probably have to make sure that it is understood it can't be either/or it's it's an integral integral even part of being a people manager and most of us are people managers being able to read spreadsheets probably isn't an integral part an important part but it's not integral so can I just give you one quick story so I was privileged to have 18 years in the Royal Navy and one of the things that the Royal Navy set up after the mutinies in the 1920s when the politicians wonderful people they are decided that a pay cut for four sailors was a good idea there were mutinies across the fleet and one of the things and this is just in the aftermath of the Russian Revolution where the Russian Navy had been the prime driver of the revolution what the Royal Navy did was it set up what it called its calls it because it's running its divisional system every officer in the Royal Navy is a divisional officer and that means their prime responsibility when they're looking after the engines or missiles or whatever their prime responsibility is they're people they're expected to know their people they're expected to know what's going on in their people's lives and they're expected to give those people support if things are not going well I would commend that to the National Service fantastic thank you very powerful thank you great another question that we've had come in I think it's important to have board buy-in but having one or two people engaged isn't going to solve it how can we improve leader and manager capability as a larger scale of course it may not solve it but it's certainly going to set the tone we're here about really changing culture so I think that that is the first thing you do want and this is sometimes a challenge your CEO and the really other top level executives to get this to really not just tick the box but but talk about this and and that is sometimes a journey for these people because it pups not what they've been expecting but there's some very very good examples so there are organizations in the NHS who did this extremely well from the top to the bottom I think when you get down then to our line managers you've really got to ensure and this may take some we're going to take investment of time and maybe resources to ensure that the line managers are people competent I don't want them to be psychiatrists or psychologists but I do want them to have an understanding of people I don't want them always to be giving the problem to HR or sending people to OAH but that they really understand the people they manage and I have been given the right training and support ring a line manager is quite a lonely business and there's a lot of stresses and strain sir how do you make these people able and capable so that they can support the people below them who will then give them of their best nothing is worse than being at work thinking I wish I was not in this place and I don't like my diamond manager so I think the reality is you have or in any group and a board is just a group of people you have to start with one or two so make sure that the one or two who are going to champion this first off that they believe it because they're not authentic it will die very fast but also that they are the people on the board who are good influences so the sort of people that others will listen to and what you'll find is that over time it will become the norm and the chair of the board can help with that with simple things so when I started going to the BT main PLC board 20 years ago now health safety and well-being wasn't even in the picture then was usually last on the agenda and invariably got squeezed and it be do you think could cover this in five minutes pull by the time I left and for many years before that it was the first item on the agenda and there was never any time pressure at all because the board from the Chairman through to all of the non execs and the nanak and the execs felt that it was an important thing to talk about so there are things that the chair can do to in board meetings to help with that but make sure that whoever is going to champion this is authentic and a good influencer great thank you okay so we've got another one here you spoke a bit about presenteeism could you please expand on why that can be more of a problem than sickness absence right so presenteeism there's been quite a lot of work done this over the last 15 years probably now it's the it's where people are at work despite the fact that they're not feeling good about themselves so they're therefore not capable of giving their all and the answer isn't just to send home anybody who might possibly be ill it's to address the underlying causes or presenteeism at hand absenteeism and try and improve the well-being of all of your people and I would just say you need to think of the sheer breadth of what can be causing presenteeism so pause mention some of them but sometimes people have got terrible carried problems at home and they haven't dared mention it for fear of losing their job that becomes more and more of a stress and anxiety domestic violence is often hidden and you have to create the right environment for that to be spoken about that that people can go to work absolutely terrified and there are whole host of things that that cause presenteeism that you need to at least be aware of and so it is enabling people to come to work able to give us their best but for us to understand these multiple causes and try relieve as many of them as we can yeah thank you I guess also be adapting things so that actually perhaps being in what might be the best for that person and maybe and making sure that that's not hot causing further harm it's doing it often is some better people to be at work with appropriate support then to sit at home than stewing yeah great thank you it's got a question here about where do you think the research in the area of well-being needs to go next so there is quite a lot of well-being well-being research it is a more difficult area than many because the evidence base is very siloed so you get evidence that comes out of the medical world from psychology from social science from economics and the evidence is all carried out in different ways using different rating methodologies and it's very difficult to compare them all that's solvable what we do find though when we review the evidence is that quite often the evidence is not as robust as one would like so very often it gives you a pointer towards what might work it will show associations but you can't say with very definitely that there is a causal link so what we need is more longer-term longitudinal studies that will pull out some of these causal effects that that's not going to be fixed quickly but it is something which the research councils are aware of and are giving considerable thought to but I would say that I I would like well-being research to have a higher profile and and I'd be if you like more weighty and the research councils can really help with this because we haven't had enough as Paulette indicated really high quality well-being research and we need we need this to be an area of development but supported by really if you like hard money from Research Council's and then done by very good researchers because that will raise it profile and and give us better better trials and and interventions and one of the complicating factors that contributed evidence base is that there are very few academics who are devoted to well-being so there just aren't there isn't the strength of a community an academic community to drive this forward but I think that is starting to come great thank you and I think we'll have to make this our final question but I'm afraid at the biggie so there's so much to solve how do you know which areas target are there specific tools or questionnaires that can be used as a measurement tool it is a huge area but I think for me you need to get in any organization because this does come down to individual organizations a baseline because not every organization will have quite the same issues now Britain's healthiest workplace era is one such tool to give you your own profile and then once by whatever means you get your profile to then choose perhaps to max three areas you're going to work on you can't do it all at once and I think you then have to decide which areas you're going to target how you're going to target and what you're going to measure so I suppose it's putting it into bite-sized bits spits so you can manage it but knowing what you're dealing with to start with yeah I would agree with that you probably already have a lot of the information that you need through your engagement service so go back and look at your most recent engagement survey and see what it is that people are saying really bothers them and make sure that those issues have been addressed so that when it comes around next time six months year whenever it is that you do it again you don't just get the same things coming up again because that's very dispiriting for people I think actually on the back of that the free texting staff survey is often the place where you find your little treasures focus on rather than just the qui tam dealers in the questions you know great that's fantastic thank you very very much for your time this afternoon I hope everybody listening in on the other side of the phone I have found that very well I certainly have so thank you very much as I mentioned earlier we've got a quick feedback survey that we'd really appreciate your thoughts on and your feedback on and yes on behalf of all of us thank you very much Dan Karen doc cool pleasure you you

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