Against a backdrop of growing waiting lists, the battle for talent and the new mental, physical and financial challenges of the financial crisis and Covid, employers are showing increasing interest in supporting employee health and wellbeing.
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But, say advisers, a lack of data is stifling their attempts to introduce more integrated workplace health strategies, make them operate more effectively and evidence the value on investment they deliver.
Delegates at a Corporate Adviser round table event last month, held in partnership with integrated health provider HCML, agreed that richer outcome data from providers would lead to better-informed strategy design and enable intermediaries and providers to present better the value of wellbeing interventions to HR professionals. Improved data would also enable greater integration across an employer’s entire benefits offering, helping to improve proactive prevention of health conditions as well as offering cures, and also support the industry in building a case for incentives from government that would nudge employers not currently offering schemes to all staff to start doing so.
Speaking at the event, Pamela Gellatly, CEO of Healthcare RM, part of the HCML Group, questioned whether the medical approach to wellbeing – responding to existing conditions rather than tackling their cause – was still appropriate. She said: “Covid was positive in a way in that it helped many people understand that health can be affected negatively by underlying causation and this can increase their vulnerability. It might be weight, inactivity, ethnicity and a range of other factors that are not normally looked at in the medical model. The data that was identified during Covid correlated with the data that we had collected over nine years which suggested that the underlying factors are very important. Within the medical model, when do we assess these risk factors? When do we address them? So when we’re assessing a clinical condition, we often look at the symptoms, but we don’t look at underlying causation, which is why we get a lot of repeat users.
“So if somebody has got a knee problem, we’ll give them a little bit of physio, but we don’t address the fact they may be three stone overweight or they’re not sleeping at night or other factors,” said Gellatly.
“We know a lot about the ill – we’re getting this from GPs and hospitals. But how about the people that are well, or the false well who are transitioning into a condition. The big thing I hear back from consultants is the challenge of achieving that behavioural change model.”
“And over the last 100 years, we’re not getting better. So why and what are we going to do about it? What we see in our data is that we often overdiagnose and overtreat.
National challenge
Speaking at the event was James Cracknell OBE, double Olympic gold-winning rower and extreme sports challenge expert, having rowed both across the Atlantic ocean and from South America to Antarctica with TV presenter Ben Fogle. Cracknell is a rehabilitation ambassador for HCML, a role that chimes with his own experience of the road to recovery following a serious injury.
Mid-way through an 18-day Los Angeles to New York cycle/canoe challenge in 2010 he was hit by a truck in Arizona, causing a serious brain injury. The accident has left him with frontal lobe damage and epilepsy, as well as an altered personality. It has also given him a keen interest in rehabilitation, health and wellbeing and the role public and workplace health can play in supporting better outcomes across the population.
Cracknell said: “I have been involved with a number of wellbeing programmes with big employers. There have been board member-specific programmes, physical health, metabolic health, sleep and stress and they have invested quite a lot of money per annum in this. But then below the board level there hasn’t been the same effort. At the same time there are employers who post-Covid now realise they need to get people back to work.
“In terms of personal responsibility, the behaviour habits we are developing are incredibly worrying. Over 50 per cent of kids who live within 400 meters of school get driven. And 80 per cent of people don’t walk a mile continuously once a year. It is projected by 2050, a third of us in the UK will burn as many calories when we’re sleeping as when we are awake.”
Gellatly cited figures indicating that over 35 per cent of the population were inactive, but added that amongst those groups with conditions the figure was approaching 90 per cent.
Cracknell said: “I was on the Number 10 Obesity Roundtable, which was formed in 2012, and then that got shelved. But when Boris Johnson got Covid badly and realised it was because he was overweight then it was evident that rather than exercise being the silver bullet for obesity, it became about what you eat and the idea that you can’t outrun a fork.”
Growing interest
Leo Savage, head of wellbeing at Howden, said employers are slowly becoming more interested in the holistic approach to workplace health. “The conversation is a hard one still because there’s always that budget constraint, but people are more open to it now, particularly if you put the right technology in front of them and make it easy for them.”
Partners& head of benefits policy Steve Herbert said: “I split it into three. You’ve got employers with no money and not much interest in doing anything for employees, with whom you are never going to make any progress. You’ve got companies with lots of money, lots of employees and importantly lots of resources to make things happen. They can employ people to run their wellbeing programs in-house as well as externally. And then in the middle you’ve got the growth area, which is those medium-sized employers who want to do something but haven’t really got that much money. So if we’re going to make a big change to this area at all, that’s where we need to focus all of our efforts as a country.”
Scratching the surface
Mercer principal James Love said most corporates would say they are doing health and wellbeing, but in reality they are only scratching the surface. He said: “If you give them a one pager, and ask them what they did – they would all tick the boxes. But unfortunately, even when they’ve got all the benefits they can’t communicate them to everyone.
“It’s also the case for those who wear the fitness watches. The data from everyone who has fitness watches will be really good. But it’s the 70 per cent who don’t who are going to struggle and cause you issues in the firm. Communication is a really big issue.”
Kevin O’Neill, associate head of workplace health at Barnett Waddingham said: “I think things are changing. We’re seeing a lot of organisations now really interested in wellbeing, whether that’s actual health or financial wellbeing. Since Covid and the financial crisis there is a growing will within organisations to improve the whole wellbeing provision. The issue that they’ve got is they don’t know how to measure it. They don’t know what they need to do for their first step to actually improve wellbeing.”
Advisers at the event said the lack of access to useful data is a key challenge to them delivering integrated health and wellbeing programmes and also demonstrating the value on the investment in employee support that the C-suite are being asked to fund.
Herbert pointed to take-up of virtual GPs, and suggested that if communications were successful, everyone in an organisation should at least have it downloaded on their phone.
But there was also the consequence that extensive use of services such as virtual GP could lead to over-prescription of follow-on treatment, increasing cost either for the employer or the NHS. Love cited a 4,000 employer scheme that had 5,000 appointments in a year. “I was seeing 60 per cent referral rates. That is a lot of people needing support, but that actually comes at a huge cost that I don’t think th industry really realises at the moment. Phoning a GP just for the worried well – £50. Then they cancel it because they have a meeting – £50. I think we’re going to see a bit of a bubble burst. At the moment it may only be a few per cent of referrals across the board but it’s just going to go up and up. And that’s not necessarily a bad thing, but it’s got massive costs attached to it.”
HCML CEO Nick Delaney said: “Simply offering access to clinical solutions will not bring an efficient outcome. So actually if we can use data to demonstrate that a different approach has better outcomes and costs a lot less, that seems the best way to try to move the market.”
NHS collaboration?
Debate moved to the potential for closer collaboration between the NHS, the government and the private sector in delivering healthcare through the workplace. Challenges remain – not least the sensitivity of being seen to undermine the NHS or create a fast-track to limited resources for those with more money. But with waiting lists soaring, delegates said there was a sense that this time the debate over incentives could be different.
O’Neill said: “There’s a problem. PMI isn’t for acute conditions. PMI providers want to do easier things. And from the conversations that I’m having, employers would love to be able to offer PMI to all staff but they generally can’t afford it. If you have a scheme and you’ve got a few cancer claims on there, the price is going to go through the roof and that impacts everyone. But there is more interest coming through for discretionary medical plans, which are really affordable. If we are looking at £10 or so a month all of a sudden it becomes cost effective for more people.”
Herbert said: “Even before Covid we had 3.6 million people waiting for treatment, Now we are at 7.2 million, which is huge – one in nine of the UK population are currently waiting for treatment.
“Clearly, for the NHS to actually get out of this hole, they need staff and funding. And the country’s pretty much broken on the funding front. So whichever political party comes in, they are going to have to do something. It’s going to be a question of how they incentivise. Most private consultants are of course also NHS consultants. So we still need more of them, whether private or NHS, because it’s the same bottleneck. But it’s going to be easier for the private side to recruit people and keep people than the NHS.”
Benefit in kind
Gellatly argued that it was unfair that when an organisation wishes to expand a healthcare plan to all employees, which is what is being encouraged by All Party Parliamentary Group working parties as part of Levelling up Health, that low income earners have to pay P11D taxation, which can be a disincentive to them joining the plan. High income earners can often afford it but low income earners may not be able to. Gellatly said she had received feedback indicating a sense of unfairness that people on lower wages were having to pay the same P11D charge as higher earners.
Another potential unfairness with the way schemes are sometimes currently administered is the fact that P11D liability is often spread at a flat rate across the entire scheme when the value to older workers is significantly higher than it is to younger ones, although this can be addressed by adopting age-related premiums.
Gellatly said: “When the government is trying to encourage employers to invest more, is it right that the employee is to be taxed on it, when your EAP isn’t taxed but physiotherapy is.”
Love said: “Push it more across onto the employers to pay for it. Even some of the big investment banks, yes, they want to add in assisted fertility, menopause and gender dysphoria and neurodiversity, which is all very expensive. The youngsters are dropping out, because the information is there for them. I saw one legal firm where they had 40 per cent of their population in. Their single rate was going up to £2,000, double what it would normally be in the City, because it was full of 40-plus people, and younger employees were thinking do I need that £500 back?”
Political issue
Cracknell, who has been in public health debates at 10 Downing Street, shared his perspective on the state of the debate in Whitehall. He said: “It’s not openly discussed inside meetings, but the one thing that keeps cropping up is co-pay.”
Vish Buldawoo, EM&T HR director at Centrica, said one of his biggest concerns was the fear that employees would opt out of the extensive integrated healthcare arrangement his organisation had put in place with HCML, just to avoid the P11D charge. He was particularly concerned that the cost-of-living crisis would fuel this trend as cash-strapped employees sought ways to get more cash in their hands by cancelling benefits.
Gellatly suggested a potential proposal that would help employers to support their employees’ health while avoiding accusations of ‘fatcat’ tax giveaways. Her suggestion was for the Government to increase the £50-per-employee P11D exempt cover level up to £150 per cover, but only for basic rate taxpayers. This would be enough headroom to enable providers to offer staff a meaningful proposition that could significantly improve health outcomes.
Holistic view
Gellatly said: “A fundamental problem with the NHS that we don’t talk about is its siloed approach. You go and see a musculoskeletal person, and they may refer you to a digestive person, then they may refer you on. So you are getting assessed several times under the medical model.”
She suggested a more holistic, individual-centric, preventative approach would lead to better outcomes.
“If we actually assessed what was going on with your weight, your anxiety, whatever it might be, and developed a care pathway or a patient journey that actually suits those needs, we could save so much.”
She said: “We need assessments that actually start looking at the multifactorial issues that impact on our health. A lot of money gets wasted sending people down ineffective pathways. The way we assess society is so siloed. When we actually do broader assessments, and look at the real data, it changes the way we think.”
Effective incentives
O’Neill said: “We have been looking at how we incentivise people to improve their health. The big problem is often incentives are largely taken up by the people that are already sold on the idea. The big problem is getting everyone else incentivised to actually think about their health. We are looking to introduce an MOT for each individual in an organisation which will look at how their health and lifestyle and shock them into doing something to improve their health outcomes.”
Preventative measures
Delegates also debated the extent to which UK workers have low expectations of their potential fitness as they age. Gellatly pointed out that government guidelines say individuals should do 45 minutes of resistance training twice a week, particularly as they get older, to preserve muscle.
Cracknell explained how, when he had, at the age of 46, rowed with a group averaging age 22 for the Oxford/ Cambridge boat race. Testing on him and his team mates had shown his resting metabolic rate consumed 1270 calories a day, whereas the younger team members consumed 2,500. “They were getting a free Big Mac meal on top of what I could eat. But people don’t understand these changes.”
Love added: “This is an education piece that doesn’t come through from employers. Maybe employers need to do something here on getting older in the same way that they’re talking to their employees about menopause and D&I. Getting older, let’s cover it.”
Culture question
Debate moved to whether there was a cultural challenge inherent in some preventative health approaches because of the risk of employers being seen to be pointing the finger at unhealthy workers.
Herbert said: “Since Covid it is much less of an issue. And we have got tools to talk to people through the web so things can be done more discretely.”
Savage said: “Consistency is key. Part of the success metric for a company is how engaged are employees. So how can we consistently give messaging around health?
“Every single week new research is coming out on how to lose weight or how to gain strength or resistance training. So by developing a roadmap of information an employer can communicate consistently around this.”
Cracknell said: “I think employers should reward behavioural change.”
Savage cited an employer where employees are given a wearable monitor and if they get enough sleep for 90 per cent of the days in the month, then they get a day or two off.
“For the 28 days that you’re coming in, you’re productive. It’s not accessible to the whole market but asset managers are now looking at integrating that. But it’s something that can give you tangible rewards and tangible data back to the employer at an aggregated level, not individually,” said Savage.
“This provider is doing research on the construction industry, and other areas to see the effectiveness of physical activity each day and how much recovery is needed. And these data points that they’re collecting from the wristband, they’re almost precursors to other conditions that the individual might not be aware of – heart rate variability, for example. This data can be a precursor to long standing chronic conditions and users get notified whether they are at risk or not.”
Good partners
Employers are increasingly focusing on the environmental, social and governance (ESG) characteristics of the suppliers they partner with. Delaney said that the private equity investors that backed him to acquire HCML are exclusively healthcare investors who are interested in impact investing – investing in companies that achieve positive societal good, and wanted to hear from benefits consultants about the ways in which employers can play a role in improving public health.
Delaney said: “We very much want to sponsor business activity which has a positive impact. If we can have a positive impact on organisations’ workforces, then that’s a big step forward for the health of the overall population. We want to hear from advisers who are interacting with employers, so we can understand what works and evolve our services and our approach to market.”