Richard Smith: Making workplace health work after 40 years of failure

richard_smith_2014What is it that makes a company successful? Could it be strategy, leadership, funding, great products, luck, or something else? All of those things are secondary to the “essence” that make for a successful company—which is the habits of the employees—argued Andrew Sykes, an actuary who is the founder of a company called Habits at Work at a C3 Breakfast last week. C3 is a global charity that works to prevent non-communicable disease.

We tend to think of bad habits, but there are also good habits. Good habits mean that employees do the right actions over and over again. Habits, said Sykes, are like the gene code of the company, running through every action, and can be compared to compound interest, which may not seem important day to day but can over time grow an investment hugely. Sykes divides habits into habits that are related to work and pivotal habits that drive the life and work of us all.

The Centres for Disease Control in the US has recognised the importance of habits, stating that they (both good and bad) account for 50% of health status when genes and environment account for 20% each and health care, which is really sick care, accounts for 10%. Health, argues Sykes, is one of the three prime drivers of the performance of individuals along with happiness and security. An organisation that has employees who are healthy, happy, and secure will outperform an organisation whose employees fall down on one or more of those characteristics. (I thought here of the NHS, where many employees are neither healthy nor happy—and may not even these days feel secure.)

Workplace health, said Sykes, has achieved few savings for companies in 40 years because it has concentrated on treating the sick, reducing risk factors, and promoting a negative view of health that means not having a disease. Crucially savings are closely related to productivity, which is something that employers (and governments) care about, and if you add programmes to increase activity and fitness to workplace health programmes then you can dramatically increase both savings and productivity. Around 85% of people don’t exercise enough, but comparatively small increases in activity (perhaps 30 minutes a day of brisk walking) can achieve most of the potential gain.

Sykes’s company has broken down health, happiness, and security into operational components—so health comprises physical (muscular strength, cardiovascular fitness, and flexibility), cognitive (episodic memory, executive function, perceived stress), body composition (body fat, BMI, waist to hip ratio), and risk factors (blood pressure, blood glucose, sleep quantity). It has done the same for happiness and security. Then it has identified 10 habits (exercise, healthy eating, sleep, etc) and related them to 35 outcomes covering cost (absenteeism, presenteeism, etc), productivity (cognitive function, error rates, stamina, etc), and life quality (blood pressure, cardiovascular disease, fatigue, etc).

The aim of the analysis is to measure in detail across all the outcomes how much will be achieved by specific “prescriptions,” and their ranking of overall impact on productivity is that increasing exercise achieves by far the most with stress management coming next, healthy eating and sleep improvements achieving roughly the same, quitting smoking achieving little (because most employees didn’t smoke in the first place), and drug treatment achieving the least. And the prescriptions are specific, so, for example, cognitive function is improved much more by two minutes of jumping up and down every hour than by 30 minutes in the gym at the end of the day.

But how can people be encouraged to take up pivotal habits? Sykes’s company has worked on this too, arriving at the formula that capability (confidence plus competence) plus motivation must outweigh barriers plus temptation for any change to happen. And this has to be worked at within a context of self, social, spaces, and systems. People have to think that they can make a change, are greatly influenced by others, need spaces, for example, to exercise, and are most likely to succeed if laws and processes encourage pivotal habits. And people will make changes primarily not to avoid heart attacks, but to be able to do their jobs better and enjoy their lives more.

Sykes ended with an example of where all of this had been put together to achieve huge health gains and a massive return on investment in a school system in Colorado. The talk had the feel of a TED and sales talk, and a sceptical member of the audience asked at the end “How do you know all this?” “I made it all up,” joked Sykes, but then repeated that the analysis was based on some 2000 studies published in peer reviewed journals and hundreds of thousands more studies that went before. Critical readers of The BMJ would not be convinced, but I have heard argued before that if we had put the same kind of study into behaviour change that we have put into drugs, then we might have made much more progress. It looks to me as if Sykes, an actuary, and his colleagues have done much of that work, but I’d need more detailed evidence than was provided in this talk. I suspect that Sykes could provide it.

Competing interest: RS was an unpaid trustee of C3 until last year.

Richard Smith was the editor of The BMJ until 2004.