Why is stress an increasing

priority for public health?

‘12.8 million Work days were lost to stress, depression and anxiety in 2004/5.

13.5 million Work days in 2007/8 costing society around £4 billion per annum.’

(HSE INDG430 2010)

Stress has always been an awkward health issue; the opening statement you’ll

likely read about stress is that we thrive on a certain amount of pressure, which

provokes productivity and drive. You’ll then read that too much pressure, a

stressor, will bring about stress and its comorbidities. That being the case, the

issue of stress is very mutable and difficult to police by public health. How are we

supposed to provide care and support to patients who for want of a better

description could be thriving?

It is also a Health and Safety issue due to the problem of work place stress. Any

stressor in the workplace, beyond a personal level of capability can be

damaging. When workers have it established that their mental health is injured

and it’s due to the employers failing in the duty of care, there is potential for

legal action. The sums involved in such litigation suggest a cost to UK employers

in excess of the costs of asbestos to UK industry.

In the landmark case of Walker v Northumberland County Council, the

complainant Walker was awarded £200,000 in damages, reduced at appeal to

£175,000 by agreement between the parties. This precedent for substantial

damages has lead to a marked increase in such cases going to court. The unions

have proceeded with about 12 cases a week. In 2000, in the case of Ingram v

Hereford and Worcester County Council, a Warden employed by the Council was
awarded £203,000, a record amount for work related stress; in the case of

McLeod v Test Valley Borough Council, the case was settled out of court, with no

liability admitted, for £200,000. (Thompsons 2010)

Such value placed on mental health injury provokes a need for the issue to be

addressed. The Health and Safety Executive (HSE) took up the challenge in the

mid nineties and has made progress in providing a framework for the workplace.

The HSE guidance ‘How to tackle work-related stress’ (2009) suggests UK

employers identify the stress risk factors and gather data; which normally entails

a stress questionnaire to staff. This is all well and good but in the majority of

cases the figures from these never identify stressors accurately enough to allow

the workplace to improve. In a lot of cases, the exercise has become a

perfunctory ‘pat on the back’, which means little to the workforce. Rarely does

this identify the injured parties or those at risk of injury due to stress. There are

other suitable tools (Stress mapping, group consults) to generate effective data,

but as with all health and safety, “reasonably practicable” precludes such

methods due to time and cost. The research undertaken by Pearce for the HSE in

2005 is very insightful with regards to such issues, and it was noted by Professor

Mike Kelly, public health excellence centre director, NICE:

"Measures such as performing annual audits of employee wellbeing are

not common practice. The financial incentives for employers adopting

these approaches are significant, however." (November 2009)

The financial implications both in lost man hours and potential damages awards

do not seem to have forced a strong enough change in Health and Safety and

Health Care. The workplace is defended vigorously by Union Health

Representatives who have more available training provided by the TUC than

most managements regarding workplace stress. Line Managers can of course

access models via the HSE website, but until a risk assessment fails or a worker

suffers and demands recompense, prevention is always a minimal measure.

As a Health and Safety Representative (BECTU 2001-2008) having been involved

in workplace stress mapping and stress reduction for an employer with over 500

staff and multiple workplaces, I am very aware that the promotion of stress

awareness and support is difficult. To be able to seek help when stressed is not

easy; and offering help to someone in need, is awkward to broach without

appropriate training. I was able to present revisions to my Employer’s Health and

Safety policy to address multiple issues including stress management and care.

Unfortunately, I was unable to promote the practical applications of such

management; causing myself undue stress and frustration.

The prevention and reduction of stress in the workplace is limited to just that;

the workplace. What do we do about our sociological and personal stress? This is

not really within the HSE boundaries and is left firmly in the remit of the NHS.

The workplace principles set out by the HSE make sound business sense but

even then, the up take of good management is poor. What chance for the public

health?

In April 2009 a ‘New Horizons’ strategy was announced by the Department of

Health to address mental health issues to build on the National Service

Framework at the end of 2009. The principle is to try and address the issues in a

primary care strategy incorporating health education.

‘Simon Lawton-Smith, head of policy at the Mental Health Foundation

commented for the press release:

"Mental ill health is one of the biggest challenges currently facing the UK.

Good mental health should be an achievable goal for everyone and mental
 health promotion needs to take its rightful place at the centre of public

health efforts. A strategy that encourages people to protect themselves

against mental illnesses like depression and anxiety will be of immense

benefit." (DOH 12th April 2009)’

As part of the government strategy, one of the most recent additions to the NHS

armoury of help lines was the NHS Stress line. Publicly stated to be in response

to the pressures of modern day life and the current economic crisis, this was

made available 30th December 2009. Multiple agencies within healthcare and

social care never had such an easy and quick referral pathway to trained

counsellors. Unfortunately, its subsequent closure had no fanfare (I still cannot

find a press article stating when); the recorded message suggests we check the

NHS choices website. The loss of the NHS Stress line within 9 months of its

inception is indicative of the failure to make such services accessible to the

clients who actually would benefit from such help. There is a critical need to

resolve this with working health promotion and marketing of services. The ten

year plan has stumbled within the first year.

To be fair to the NHS and their own direction, they have created a NHS presence

on the Internet which is now very established and quite user friendly

(www.nhs.uk). The public demand to be able to self-diagnose and arrive at the

GP with some indication of what might be wrong is actually well served with

regards to stress and depression. Self awareness in such matters is the only way

a lot of cases of stress will be dealt with. Unfortunately, a large majority of stress

cases do not present to a healthcare professional or seek help. A fair few will

turn to alcohol or other drugs; and some will harm themselves in other ways.

(NHS Choices 2010)

With the general increase in stress related sickness, stress will indeed remain a

major healthcare issue for the longest term. In the last 15 years, no concrete

progress is apparent barring ‘New Horizons’ which is still teething. The

determinants of our health will always increase in number, directly or indirectly

affecting our stress and capacity for it.

How we as a society come to terms with the idea that injury to our mental

health is as important and valid as an injury to our physical self, will require far

more health promotion from the government and the health services. The poor

take up of recently available services suggests the stigma associated with

mental illness extends to stress. (There is a current radio advertising campaign

on Absolute Radio by ‘Time to Change’ with regard to mental health prejudices

which is I believe a small step in the right direction. )

The workplace must be far more pro-active in making the Management

Standards work; Develop solutions, implement action plans and then assess.

Those standards are very well presented as Demands, Control, Support,

Relationships, Role and Change. Effectively, these are the Workplace

Determinants of Stress. If employers do take these principles to heart, public

health as a whole will benefit; the management standards are, currently the

easiest and most accessible public resource with regards to stress.

As individuals, we need to be able to recognise our capability to endure pressure,

to know when something is beyond our threshold, to be able to ask for help. I do

not believe the current way that stress is presented as being both positive and

negative allows us to do so without guidance; and that is just not immediately

available.
Stress will become a greater issue before it is addressed properly. We are again

at the ideas stage of management; there is the New Horizons ten year plan, but

that’s a long time when you are suffering a mental health problem.

[WORD COUNT 1519]

References

DEPARTMENT OF HEALTH (2009) A new vision for mental health and wellbeing
Press release from the Department of Health, 12 April 2009 [ONLINE]

Available at :< www.lcr.nhs.uk/Library/Anewvisionformentalhealthandwellbeing.doc >

[Accessed 6th October 2010].

HEALTH & SAFETY EXECUTIVE (2009) How to Tackle Work-related Stress; A Guide for
Employers on making the Management Standards Work [ONLINE], INDG430. HSE Books.

Available from :< www.hse.gov.uk/pubns/indg430.pdf>

[Accessed 4th October 2010].

NHS Choices (2010) Stress [ONLINE], last reviewed 22/06/2010.

Available at :< www.nhs.uk/conditions/Stress/Pages/Introduction.aspx>

[Accessed 4th October 2010].

NHS Choices (2010) Nine types of drinkers [ONLINE], last reviewed 15/08/2010.

Available at :< www.nhs.uk/livewell/alcohol/pages/drinkertypes.aspx>

[Accessed 6th October 2010].

PROFESSOR MIKE KELLY (2009) Statement in conjunction with NICE guidance launch
regarding mental wellbeing promotion with employers [ONLINE]

Available at :< http://www.hrmagazine.co.uk/news/964482/NICE-challenges-employers-cut-

workplace-stress/ >

[Accessed 4th October 2010].

PEARCE J (2005) Attitudes, opinions and experiences of attendees at the ISMAUK stress
workshops 2004 [ONLINE], HSE research report 389, HSE Books.

Available from :< www.hse.gov.uk/research/rrpdf/rr389.pdf>

[Accessed 4th October 2010]

THOMPSONS (2010) Summary of the law on STRESS AT WORK [ONLINE], Last updated
May 2010.

Available from :< www.thompsons.law.co.uk/ltext/l0780001.htm>

[Accessed 4th October 2010].

TIME TO CHANGE (2010) Absolute Radio Web content for the current advertising campaign

Available at :< http://www.absoluteradio.co.uk/freebies/timetochange/ >

[Accessed 6th October 2010].