Barriers and facilitators to implementing workplace health and wellbeing services in the NHS from the perspective of senior leaders and wellbeing practitioners: a qualitative study

An interview schedule was employed to ensure consistency across interviews. Questions in the schedule included:

The interview schedule for practitioners was adapted to cover implementation of workplace HWB services and included additional questions such as:

Another perceived consequence of staff shortages was that those people responsible for the implementation of HWB services were also under pressure. This was perceived to have negative consequences on their ability to deliver effective and resourceful HWB services, as explained by one head of HR:

Everybody who is delivering those services is running to a standstill and we don't necessarily have the time to step back and say actually, could we do this in a better way, could we actually deliver this by doing things differently maybe even free up some resources to do things.

010, HR

Another barrier to NHS workplace HWB services was the perception that the money available in the NHS should be prioritised for patient care rather than staff HWB. Some respondents held the belief that the NHS is traditionally viewed as a service that cares for and invests in services for patients, not its staff. Some respondents (n = 4) expressed a concern that compared to a private organisation, the NHS as a public body would be criticised by the media and general public for prioritising staff HWB initiatives over patient care:

In the private sector, health and wellbeing can be supported, because at the end of the day it’s being paid for out of shareholders’ money; in the NHS I think there is awareness that because we’re a public sector employer we are actually spending taxpayers’ money.

010, HR

I think if you’ve got a story out there and the press get a hold of it or, I don’t know, £40,000 was spent on health checks for staff, but actually then the next story is we’ve got people waiting in A&E on trollies, there would be that whole thing of, well, why are they spending money on health checks for staff?

007, HR

Respondents referred to fundamental characteristics of the NHS work environment that made staff engagement with workplace HWB services difficult. The main logistical barrier was believed to be the time constraints associated with shift work. Long shifts limited time for staff engagement with HWB services and variable shift patterns produced a demand for HWB services 24 hours a day, 7 days a week. One head of HR explained the time barriers associated with staff engagement with exercise classes:

You’ve got people working different shift patterns...Which is one of the reasons why I think some of our exercise classes are not working, because the people that have said they want them want them at eight o’clock at night or nine o’clock at night or six o’clock in the morning or seven o’clock in the morning when, you know, when they finish their shifts. And I think that’s the problem is we’ve got such a diverse workforce.

002, HR

Respondents also identified logistical issues that made access to HWB services difficult. In Trusts situated across multiple sites, some staff members did not have direct access to on-site HWB facilities and services. Access to facilities was also impeded by the limited space available on site. One practitioner described the logistical barriers to staff engagement with HWB services:

With some of the exercise classes, because we are over three different sites that's been met with a little bit of resistance. And although class numbers have been good, I think because people do shifts they, it's not at a reasonable time or because we haven’t been going to the [other] sites, people have taken offence to that. So we're having to work around it.

008, P

The perceived barriers to staff engagement in HWB services were not always about logistics of delivery or organisational infrastructure, but related to individual-level motivation in the workforce. Some respondents held the belief that staff members should be held personally responsible for their own health. The common belief was that staff, “have got to be motivated to do it” (003, SL) and that generally speaking, they “don’t have an interest in it” (008, P). Consequently, the success of HWB services was believed to be dependent on individuals understanding the importance of HWB, taking personal responsibility and being receptive to workplace HWB services. One senior leader explained:

There are a lot of unhealthy people in the NHS and I think that it comes down to personal responsibility. And I think maybe if they knew what impact it was having on their health they may have taken more of a responsibility.

009, SL

All respondents were aware of government schemes and funding initiatives such as the Five Year Forward view, commissioning for quality and innovation (CQUIN) and local funding awards. Most respondents were ambivalent about whether government schemes and initiatives were an incentive to initiate change in workplace HWB services in the NHS. Such incentives were considered to have mixed, positive, negative or no impact on the Trust’s HWB agenda. Respondents who spoke positively about government schemes and funding perceived it to be a catalyst for change because they:

1. 1.

   Raise awareness about the importance of HWB at the Executive Board level

    
2. 2.

   Are a powerful incentive

    
3. 3.

   Encourage consistency across organisations

    

Respondents believed that government schemes such as CQUIN raise awareness about the importance of staff HWB and as a result, workplace HWB services are prioritised at the Executive Board level. One HR Lead explained how CQUIN helped to prioritise the HWB agenda at the Executive Board level:

In October our bombshell hit. And if I’m being honest it totally wiped the health and wellbeing item off the agenda. It wasn’t top of the priority list. It was on mine, but I wouldn’t say it was at, at Board level or, or managers’ level and I think particularly the CQUIN has brought it back to the table, because there’s a penalty now if we don’t achieve what we’ve been asked to achieve.

002, HR

There was consensus among four practitioners and heads of HR that government schemes were a powerful financial incentive, as explained by one HR Lead:

In a cash-strapped service it is sadly the reality that you have to have some sort of financial motivation to do it. So, from that point of view both the CQUIN and the Healthy Workplace Initiative that offered us match funding to do things is very helpful.

010, HR

One senior leader mentioned that government schemes and initiatives make HWB services consistent across Trusts:

It's enabled the NHS to move forward together adopting similar approaches in certain areas that are covered by the CQUIN which then means that wherever you go in the NHS you're getting a similar sort of approach, so you're getting a bit of reinforcement.

004, SL

This structured approach was also considered beneficial by a head of HR:

We’re signed up to a [name of award] Award. So that is looking at five different areas so around substance use and misuse, healthy weight, mental health and wellbeing, protecting health, so things like cancer, domestic abuse, those kind of things and then health and safety. So that award gives us a real structured approach to how we try and take things forward… We achieved bronze last summer and we’ve just submitted our silver. So that gives us a real structured focus...this is obviously much more holistic and in depth assessment rather than just the NHS Health Check.

002, HR

Respondents believed that the main drawback about government schemes were that they frequently lacked support from adequate funding or resources. This view was shared by senior leaders and heads of HR, who believed that they did not have the resource capacity to succeed;

I think [CQUIN] helped in the sense of raising awareness, of course it's not been backed by huge resource, so it's one thing to sort of say that it's important but it's another thing to actually back that and support it properly.

009, SL

My frustration is still accessing the resource needed to achieve [government scheme/award] and achieve it well, you know. I think that’s my concern is I’m doing things so thinly and at times don’t think we’re doing things particularly well, because we just haven’t got any additional capacity.

002, HR

Another negative viewpoint was that the introduction of schemes and funding did not change or add to already-established HWB services. Whilst there was an appreciation that the schemes could be useful for putting HWB on the Executive Board’s agenda, in Trusts where a HWB strategy was already in place, schemes and charters such as CQUIN were perceived as having little impact:

I don’t think it’s particularly changed the mind-set, but I think because we’re doing quite a lot anyway... the CQUIN is about, what are you going to do in the future, as opposed to acknowledging what you have done already-... so there's nothing really that's prompted us [to change].

001, HR

This subtheme captured the characteristics of the organisational structure believed to facilitate implementation of workplace HWB services in the NHS. All respondents agreed that support was required at all levels of the organisation; from the Executive Board to the front-line HWB practitioners. Three main levels of support within the organisational structure were believed to help HWB implementation:

1. 1.

   To have a supportive Executive Board

    
2. 2.

   To have managerial engagement

    
3. 3.

   To have dedicated HWB staff roles with the relevant skills and expertise

    

Support from the top-down was considered essential for the successful initiation of workplace HWB initiatives in the NHS. Respondents referred to the importance of “the Board being on board” (001, HR) with workplace HWB initiatives. At the Executive Board level, HWB had to be considered a priority. Practitioners, HR Leads and senior leaders believed it was particularly beneficial when the senior leader had an existing interest in HWB (personally and/or professionally) and was a role model for HWB behaviours; “You’ve got to practice what you preach” (004, SL). However, enthusiasm and intention from high-level individuals was inadequate to initiate change in the implementation of workplace HWB services, especially when Trusts are constrained by other targets and lack supporting funds and resources. One head of HR explained how senior leaders may value staff HWB, but are under constraint from targets in other areas:

People pay a lot of lip service to [staff HWB], but I think there are a lot of people in senior positions who say, oh yes, yes, we do value it, but actually then don’t truly understand it, and when they then have constraints put on them around targets to meet, I don’t know, certain cancer services for example, that then becomes the priority because that’s what the press pick up and that’s what’s in the headlines.

007, HR

Support at the managerial level was also considered key to the success of initiating workplace HWB services. There was consensus across respondents that managers need to value workplace HWB and be supportive of their staff attending and engaging with HWB services, so that they can communicate the value of HWB to their staff. This was described by a practitioner and a senior leader:

I think if [managers] have an input on directing staff to the appropriate service and getting them interested, then it should work more effectively. But if they don't, then there's a breakdown.

008, P

The key to embedding [workplace HWB services] and this becoming a central part of what we do, will be the extent to which we can get our line managers, our middle managers to see it as really valuable in terms of those wider issues which they’re responsible for delivering in terms of caring and cared for staff.

005, SL

The practitioners who had experienced success with initiating workplace HWB strategies described how managers were receptive and, “really supportive towards it, really welcoming to come to team meetings and to talk to people about it” (006, P). It was acknowledged that for managers to fulfil this supportive role, training and upskilling of managers would be required to help them understand the importance of HWB and communicate the messages to their staff:

That’s the biggest thing with this, with health and wellbeing and part of the CQUIN is around that line manager support, their training, their understanding as to why health and wellbeing is so really important, so that they can then cascade that down to their staff.

002, HR

Having a dedicated HWB lead role in the organisational structure was important for the successful implementation of workforce HWB services. HR staff in particular believed it was important to have a clearly outlined HWB job role with well-defined expectations. This role was said to benefit from being a protected role (i.e., not given other responsibilities) and benefitted from having relevant skills and expertise in the area of HWB. Respondents spoke about how the HWB role has adapted from the traditional occupational health service (OH) and this change has been met with some conflict and job ambiguity. One head of HR described this challenge:

I’m trying to change the image of the team; that it’s not an occupational health team, it’s a health and wellbeing team and, you know, they hate the fact that I’ve took occupational health out of their job titles. They’re now 'wellness nurses' and that hasn’t gone down well at all.

002, HR

Respondents were aware of the different approaches taken by HWB and OH, with HWB taking a more preventative approach than the traditional reactive model of OH. There was consensus among practitioners, heads of HR and senior leaders that a transition towards a more preventative approach is required for the success of workplace HWB initiatives, as captured by one head of HR:

An analogy I’ve used in the past is that we’ve got this bucket of sickness absence in the Trust and the Trust strategy is to try and empty that bucket by bailing it out. Bailing it out is basically, sadly, terminating people with long-term sickness absence or short, recurrent short-term sickness absence, but nobody has stood back and said, hang on a minute, how do we turn the tap off and in my mind turning the tap off is the preventative bit and that’s where the focus needs to lie. It’s no use carrying on, it doesn’t matter how fast you bail it out, if you don’t turn the tap off it’s going to carry on overflowing.

010, HR

This subtheme captured the notion that taking a preventative approach to workplace HWB requires a change in the whole NHS organisational culture. Change would involve “trying to change that culture to make people understand the importance of staff health and wellbeing” (007, HR). One head of HR and a senior leader gave examples from their own Trusts of how environmental changes could contribute to this cultural shift:

We swapped the cost of chips and the cost of salad in the staff canteens, because we thought it was ridiculous that chips were cheaper than salad, so we persuaded the catering manager to swap the pricing so that chips were more expensive. And also to move all the chocolate and cakes and things away from the tills and put the fruit and so on nearer to the tills.

010, HR

We've been completely smoke free now for about four months...people are not allowed to smoke during working hours.. so that's been fairly effective.

003, SL

The benefit of having a strategy in place included having a common goal, for example: “knowing what they’re all working towards within a Trust” (007, HR). However, the majority of practitioners and senior leaders alike perceived scope for improvement in their Trust’s HWB strategy:

[The HWB strategy] hasn’t really been picked up, so to be perfectly honest with you there isn’t a decent strategy in place actually. It’s meant to be part of another overarching strategy, but it doesn’t link and it’s the kind of thing that’s out of my control.

007, HR

In Trusts without a clear HWB strategy, respondents described how the approach to implementation tended to be opportunistic interventions delivered individually, for example:

It would be helpful to have an overall, an overarching strategy, I think that would be helpful. And we've not pulled it all together, there's lots of different initiatives but pulling it all together would be of benefit I think.

003, SL

We have developed a range of interventions, but they’ve tended to develop separately and I think one of the things that we need to think about is how we’re offering our staff a coherent approach to health and wellbeing, and in a sense more of a single portal through which they access that.

005, SL

A common belief was that an all-encompassing system of HWB services would benefit the strategic approach to implementation. Some respondents suggested a whole-systems approach would be beneficial. This all-encompassing system would involve a smooth referral scheme, whereby staff could be referred to any number of different services offered by the Trust or by the local community (e.g., smoking cessation, financial help etc.). This approach was described as working effectively by one of the practitioners interviewed:

Because we were part of the healthy living service, we were able to directly refer people in to the healthy living service, so we were able to refer people straight into the stop smoking service, the healthy living service …So that made a big difference I think, as a practitioner, having the ability to refer people and give them that support straightaway as well. …So for example people may have said, I need support with weight loss, so you were able to, with their consent straightaway say to them, right, this is healthy living service, you can be referred straight into it. There’s the gym membership I can offer you, and you were able to show people and direct people straight onto that, which I think was really good as well.

006, P

Effective communication and advertisement of the HWB services on offer within a Trust was another perceived facilitator. Respondents described the best techniques for effective communication as physically going out to the workforce and having presence on the ground with messages. One head of HR described how the Trust had experienced successful communication in the past with a flu vaccination campaign:

Interventions in our Trust that have worked well - flu is one that as an organisation, apart from last year, we’ve excelled at over the previous four years and a few people have said to me, why did you do so well? Because we went to them...We physically go out there. We know that staff struggle to even come down to the canteen and get a break, so when we’re putting on displays and events, they just physically don’t do it.

002, HR

Word-of-mouth techniques for communications and advertisement, as opposed to email communication were believed to be a successful method for making staff aware of the HWB services available.

Respondents described HWB budget constraints and referred to the importance of being creative and innovative with what limited resources were available for HWB services. Creative techniques involved utilising external partners and organisations and being efficient with resources. Respondents who had experienced some success with HWB implementation described how they had fostered good relationships with external partners such as workplace wellbeing organisations, local councils, local gyms and businesses. For example, one head of HR said; “partnership working and relationship building is so crucially important and often when that’s working well, you can pull in on some of that when you need to pull in on it” (002, HR). The perceived benefits of forming partnerships such as these included having shared resources, for example:

I also contacted the Physical Activities Coordinator within [the local council], met up with them, looked at what sort of joint work we could do together, …a bit of a partnership with them so they send us resources that they have on offer.

006, P

Sharing knowledge and expertise with external partners was perceived as a catalyst for change, for example, “without their [external HWB organisation] direction we probably wouldn’t have implemented it” (008, P). The benefits of utilising external partners extended to the ability to receive formal training, for example:

We’ve got a company came in called [name of company], so again they trained, I think it was about 140 odd managers and that’s about, how do you recognise and spot that individual members of staff are getting a bit anxious and a bit stressed. So it’s to try and prevent, prevent the absences.

001, HR

Being efficient with available resources was mentioned as important in organisations with constraints on HWB budget. Suggestions for how Trusts can be more efficient with resources included employing administration staff, fostering relationships with on-site Estates services and seeking alternative sources of funding. For example, one senior leader explained:

We're moving into how we can access softer sources of funding, and OK maybe we can't put a programme on that covers 90% of what we wanted to do so let's, so we're going to put on programmes that cover 5%, but it's a start.

004, SL

Respondents acknowledged the importance of meeting workforce needs with workplace HWB services and considered a needs analysis to be an important facilitator to implementation. One head of HR explained how the needs analysis can inform the HWB strategy:

One of the first things I did when I came into post was do some baseline data with some staff first just to kind of ascertain, you know, the health behaviours and status of staff and what they wanted and the type of things they think would help them lead a healthier lifestyle. And used that to inform the strategy, looked at our health profiles and compared them with local health profiles to see just exactly where some of our troubled areas are and also just generally find out what staff want.

002, HR

Three senior leaders mentioned that previous attempts to engage staff in HWB initiatives have struggled to “reach the people who really need to do it” (003, SL), suggesting that a needs analysis might help to identify those people and subsequent solutions.

A robust evaluation of HWB services was regarded as important to demonstrate positive outcomes, support funding applications, give credibility to the HWB service and to improve the service for the future. Respondents valued being able to share successes with employees and the Executive Board, because this was believed to help justify the need for the HWB service. One head of HR described how results from HWB service evaluation could be used to promote staff recruitment:

[Evaluation] is about demonstrating that we do care about our staff. Our strapline is we care and I think it’s important, particularly within NHS where often we struggle to recruit staff, particularly our nurses and doctors, if one of the unique selling points is going to be that we do care about our staff and we can demonstrate that and we get some recognition for doing that then, you know, that’s really quite important.

P002, HR