Health and well-being in small and medium-sized enterprises (SMEs). What public health support do SMEs really need?

Introduction

Health and well-being in the workplace presents a fundamental business case for a productive, happy and healthy workforce. In his 2004 report on public health, Wanless stated that ‘Employers have much to gain from considering the revenue implications of preventative health for their business.’ ¹

He concluded that companies in both the private and public sectors could benefit greatly from investing in their employee health and well-being; in particular, preventing ill health and disease. Black’s 2008 review of the health of Britain’s working age population estimated an annual economic cost of ill health, in terms of working days lost and worklessness, to be over £100 billion. ² The review concluded that ‘Improving the health of the working age population is critically important for everyone, in order to secure both higher economic growth and increased social justice.’ ²

The key objectives derived from Black’s review are to prevent illness and promote health and well-being. ² For those who develop a health condition, it outlines the need for early intervention and an improvement for those who are unemployed, so that they have the potential to work. The Government’s response in Improving health and work: Changing lives ³ suggests a range of initiatives built around three goals: creating new perspectives on health and work; improving work and workplaces; and supporting people to work.

The ideology of the health-promoting workplace is recent and underpinned by the concept of the settings approach^4,5 suggesting that ‘Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love.’ ⁴

The settings approach places health and well-being at the very heart of an organisation, ensuring that the everyday activities of the organisation are committed to health and well-being. ⁶ The commitment to workplace health promotion (WHP) results in a wide range of activities and measures, with outcomes at individual and organisational levels ⁷ that can have a positive impact on the workforce. ⁸

Small and Medium-Sized Enterprises

Small and medium-sized enterprises (SMEs) are a significant contribution to sustained economic growth and the development of employment globally.^9,10 This makes WHP vital within these settings. ¹¹ Research into SMEs and WHP is limited. The inability to tailor to the health promotion needs of SMEs and, subsequently, the attempt to implement strategies and interventions used in large organisations (e.g. mental health literacy workshops or stress management training) are inappropriate and difficult for SMEs to adopt. ¹²

SMEs have been identified as being both hard to reach and difficult to change. ¹³ This is due to a lack of knowledge, resources, motivation from managers, employees and the inability for occupational health services to access SMEs. ¹⁴ This poses a significant challenge for health professionals, occupational health services and those involved in policy development. ¹³ The issue of concern regarding SMEs access to appropriate health and well-being services was highlighted in Black’s review on improving health at work. ² Furthermore, evidence from a joint survey by the Advisory, Conciliation and Arbitration Service (ACAS) and The Chartered Institute of Personnel and Development (CIPD) suggested that both employers and managers in SMEs are dealing with a complex range of needs in order to manage health and well-being in the recession. ¹⁵ As a result, SMEs may not be in a position either to invest in occupational health services or access available services. ¹⁴

In the current economic situation in England, SMEs due to their size cannot afford to lose their labour force for significant periods. The need to re-organise workloads due to sickness absence can present a significant problem for SMEs due to lower employee numbers. Consequently, the prevalence of presenteeism could be considerably higher than absenteeism in SMEs.^16,17 This continued work presence may also be a problem for SMEs as due to their size, the reliance upon the adoption of multiple roles and interdependent team productivity increases the chance of people working while unwell.^17–19 North West England has distinct health inequalities attributed to levels of economic activity. Sickness absence in the region is among the highest in the country. ⁷ Hence, the North West faces work-related challenges, which need addressing to improve the economic profile in the region. Public health professionals in the region are in a position to develop interventions, which can support those in jobs and those seeking employment. They can also influence the extent to which work and the workplace affects health and well-being outcomes. ¹¹ This article reports findings from a small-scale study of SMEs across Greater Manchester. Suggestions are that SMEs have specific health needs, struggle to access occupational health services and are difficult for health professionals to reach.^13,15 This article aims to identify the main health and well-being needs of a sample of SMEs across Greater Manchester and the support that public health professionals can offer.

In this study, the definition of presenteeism is attending work even when one feels unhealthy. ²⁰ Absenteeism is absence from work attributed to sickness by the employee and accepted as such by the employer. ²¹ The European Commission definition of SMEs has been used as micro < 10, small < 50 and medium < 250. ²²

Methods

A qualitative approach underpinned by a Health Needs Assessment (HNA) framework was used. Figure 1 which we adapted from the National Institute for Health and Clinical Excellence (NICE) Health Needs Assessment Toolkit ²³ illustrates the different steps that were utilised for the purpose of this study. Previous work with SMEs undertaken by the research team showed that recruitment to research from busy SMEs could be problematic. ²⁴ Telephone interviews are a good approach to obtaining self-reported outcomes, experiences and are more cost-effective in terms of time, money and effort on behalf of researcher and participant.^25,26 The use of telephone interviews in our previous work with SMEs ²⁴ had proved successful for us in gaining access to what is proposed a difficult group to reach. ¹³ An initial telephone call was made to the SME owner/manager to ascertain their willingness to participate. In all cases, those who did participate did so immediately as time constraints were a key issue, and it was necessary to keep the interview time to around 5–10 min. Our previous experience in telephone interviews with SMEs had highlighted to us the need to be succinct and consider these time constraints. Quite simply if the interview took too long, the person on the other end would end the interview. The research university’s ethics committee gave ethical approval for the research. Semi-structured questions were used and the answers transcribed:

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Figure 1

Health Needs Assessment Toolkit (adapted) ¹⁴

Sampling Framework and Analysis

A convenience sample of SMEs were used from the 1,500 data list of SMEs made available by the Commission for New Economy Manchester. The types of SMEs were grouped into five categories (Table 1). The research team (two interviewers) undertook the telephone interviews randomly selecting from the data list of both public- and private-sector SMEs across the five categories. The predominant size of SMEs who agreed to participate in the study was micro < 10 and small < 50 employees. All telephone interviews were carried out with SME owners/managers. Saturation point was reached at 91 interviews. Definitive conclusions from small-scale studies cannot be generalised. They are, however, useful for gaining information from specific groups and subgroups in a population. ²⁷ Data were analysed by the research team using thematic analysis by identifying repeated patterns and themes within the data. ²⁸ Interpretation of the data was not checked out with interviewees.

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Table 1

Number of interviews by type of SME.

Category	Number of interviews
Retail	26
Manufacture	42
Legal	6
Finance	7
Catering	10

SME: small and medium-sized enterprise.

Results

The findings are presented as broad themes that emerged from the telephone interviews. Unedited data fragments are used to illustrate themes and SME category, and employee sizes are illustrated.

Types of Sickness and Ill Health

The predominant cause of absence from work (other than holidays) was reported as short-term illness such as colds, flu and viruses such as norovirus. These acute problems were equally distributed across organisations, which employed both male and female employees:

I would say general illness has resulted in the most sickness days for us. There is a definite seasonal influence, it’s been all colds and flu through winter and in summer it’s like food poisoning and hay fever from the barbeques and things. (Manufacture < 50)

Tummy bugs and colds mostly its always general illness that tend to result in the most sick days for us. (Retail < 50)

Sickness and absence is one of the areas that affects small businesses both financially and in its productivity. The impact of such acute episodes within this study on the workforce and productivity was highlighted:

Colds and flu come round all the time and once one person gets it, it can spread like wildfire through the workforce. (Manufacture > 150)

One organisation reported that in a staff population of 30, they had 26 episodes of short-term seasonal illness in that quarter.

Acute seasonal illnesses in this study had a major impact on catering businesses and hotels. These organisations reported being at their very busiest when colds and viruses were at the highest level, such as the winter and Christmas/New Year periods:

The trouble is acute illnesses need rest and businesses like ours are at their busiest when the rest of the country can rest such as Christmas holidays. (Catering < 50)

The need to recover from these acute illnesses but being unable to do so was seen as a significant problem.

Authenticity

A recurrent theme of authenticity and illness reporting occurred in some organisations and was not specific to either male- or female-populated organisations. Authenticating illness was linked to those who presented at work with a cold or virus in order to prove or need to prove (authenticate) their illness:

Yes we have a lot of people off sick but they swing the lead in my opinion. I suppose there are genuine cases though. (Retail < 10)

The beliefs about health and the perception of the legitimacy of ill health are based on a number of factors such as individual experiences of ill health and disease and social perceptions. ²⁹ These beliefs then form the individuals own moral position on absence and attendance at work and subsequently inform their decisions relating to this: ²⁹

I guess there would be the odd person who would take sick time off but say they were sick. (Manufacture < 50)

An alternative view was that some people used certain problems such as stress or physical issues inappropriately or to explain an absence:

Stress and anxiety, workplace injuries are sometimes an issue but I think half the time people are just putting it on because they see colleagues get away with it. (Manufacture < 50)

This offers some explanation as to why employees with psychological issues, such as anxiety or depression, come into work when unwell to prove their ill health to managers and colleagues. Remaining in work in order to prove their legitimacy of sickness when employees should actually take sickness absence can contribute further to or exacerbate psychological issues.

Another theme associated to the concept of authenticity was that of using up paid ‘sick days’ or sick pay entitlement as a way to extend annual leave. There was a general feeling across some organisations that staff used their annual paid sick leave quota as additional holidays, while reporting them as sickness. This, it is estimated, cost 2.7 billion from 30.4 million days of non-genuine sickness to the UK industry in 2011. ³⁰ The underlying issue around the abuse of sickness absence or taking leave when it is not justified adds again to the pressure of proving genuine illness for some employees.

Sickness Presenteeism

The predominant reason for sickness absence in this study is short-term illness. However, it was clear from the responses that employees are more likely to also present at work with such acute episodes, causing significant problems of cross infection of viral disease. Sickness presenteeism therefore appeared to be more prevalent than sickness absence:

I think in these times people are more likely to have financial worries and would find it hard to take time off. People just get on with it. (Manufacture < 100)

Sickness presenteeism occurs when employees come to work when they would be justified in taking time off for either physical or mental ill health, or both. It is becoming an increasingly recognised problem.^31,32

Employees across all types of organisations presented at work when they were unwell. This is most obvious in micro and small organisations where the impact upon staff, if people do not come into work, is clearly felt and often reported as an inability to ‘carry people’ who are off sick:

We don’t really have any health problems but we’re so small we could not afford to carry anyone. (Legal < 10)

Such reports are in line with those who suggest that relationships with colleagues, working in a small group, working non-standard hours and cooperation between employees increased the probability of sickness presence.^31,32 This idea of personal relationships and the family imagery in workplaces was also linked to sickness presenteeism. For many, this intra-‘personal’ relationship was a central feature of work:

People come in as they know it would be a problem for everyone else if they didn’t. (Financial < 10)

Sickness presenteeism in family-run organisations was again seen as inevitable:

Well this is a family business so we could not afford to let things like that affect the business. (Legal < 10)

Thankfully we don’t have any real health issues and because we’re brothers running the family business we just come in when we’re poorly. (Legal < 10)

Others reported the difficulties of family-run businesses, where it is not possible to take time off for sickness:

We don’t take time off or sickness days. We’ve had to put our business before our health I suppose. (Financial < 10)

We drag ourselves in. (Catering < 10)

The high levels of job demand alongside long working hours for family-owned/run businesses are well documented. ³³ Such organisations record far less sickness absence and go to work when they are ill. ³⁴ Family-run/owned SMEs were also concerned about the financial implications on their organisation, if people were absent from work:

We are a very small organisation with individual responsibilities. There is no one to do these if people don’t come in and the clients get very angry and then don’t pay us. If they don’t pay us we don’t get paid. (Retail < 10)

The experience of financial difficulties was clearly associated with sickness presenteeism both in the family-run/owned SMEs and those who employed other staff. It was suggested that there are worries from employees who are facing the impact of the current economic climate and who simply cannot afford to take time from work financially:

We have mostly manual shop floor workers and they only get statutory sick pay so that is the incentive to come in. (Manufacture < 50)

For employees whose wage structure depends greatly on additional pay supplements, there are clearly financial incentives for presenting at work when unwell. ³²

The type of job that people did and the levels of income and professional level were an indicator as to whether employees would, or should, take sick leave:

We are in the middle of a council estate which is very big working class area so all are employees are very hard working people and they don’t take time off if they get sick they just get on with it. (Manufacture < 100)

Alternatively, other interviewees reported a culture of illness among this group as one that reported unnecessary sickness and false absence. The latter would support the fact that lower paid and lower skilled workers were more likely to take time from work due to illness. ²

At the other end of the polarity, those in higher or highly paid professional jobs reported an organisational culture, which expected them to go into work when ill. In addition, that the experience of sickness was something that was an inevitability, which came with the job. This inevitability was more prevalent across legal and financial organisations:

Well as you can imagine we work in a stressful environment and we work long hours but that’s what we signed up for and we just get on with it. (Legal < 10)

These findings have some resonance with work on the personality characteristics associated with sickness presence. ³⁵

Public Health Support

Almost all the interviewees would not necessarily seek any general further support for health and well-being problems in their workplace. The only significant exception to this was support for managing acute and seasonal illness. There was a genuine interest in the provision of preventative services in the workplace such as the flu vaccine:

Absolutely yes! Approximately 45% of our warehouse-working environment is at extreme temperatures (approx. -25 to -30°C). This means that some of our staff are more prone to illness than other staff such as accounts office staff. (Manufacture < 100)

Some of the managers/owners would seriously consider a preventative workplace flu vaccine service, if it was a need identified by their employees:

If this was something employees needed/required then, yes we would definitely look into supplying this. (Manufacture < 50)

Micro (less than 10 employees) and smaller organisations were particularly interested in the service being offered on site. Managers/owners reported that they would offer time within working hours for the service on their premises:

I would be happy to allow half a day during work hours for this to take place. Maybe a morning to save people taking time off to do it. We are a small business so staff absence affects us very negatively. (Retail < 10)

This related to the need to limit a reduction in productivity in both time off sick and time from work to have the vaccine from their general practitioner (GP):

Absolutely yes. If it meant not having to have them independently at the GPs office. We would be very interested. (Catering < 10)

Yes. We are only a small business so if people are off sick, or take time off to have jabs it affects us more. (Financial < 10)

It was also considered as being potentially appealing to those employees who are not paid when they have to take sick leave or absence from work for GP appointments:

When people take time off to have these jabs, they don’t get paid for it, so it would probably be very appealing for them to do it this way as it’s during the work day. (Manufacture < 10)

Managers/owners while supporting the idea would not necessarily pay for it and neither they thought, would their employees:

In this current climate, possibly not. Times are very hard in the retail sector at the moment and staff’s pay does not stretch as far as it used to. I think people might be reluctant to pay for this. (Retail < 50)

There was some suggestion of organisations offering a contribution if the vaccine could be provided at a reduced price:

Maybe a small fee of under £5 if we really had to but otherwise, I would not like to pay for this given the current climate and the current state of the business. (Retail < 50)

Alternatively, it was suggested that certain service costs in providing such a preventative service may be supported:

I would consider contributing towards the travelling costs of a medical professional to attend my site in order to administer the flu jabs as it is convenient for me and my staff. (Financial < 10)

There was a particular interest in how other SMEs might have already initiated preventative services such as this and what impact these services had. Managers/owners would welcome more information on case studies of good practice.

Discussion

The idea that both private and public sectors could benefit from investment in employee health, in particular providing preventative services, is well documented.^1,2 This small-scale study has identified that while long-term illness may occur for some organisations and employees, it is not considered a pressing problem for those SMEs within this study. Acute illness such as colds and viruses are those health needs causing the most problems for these SMEs and their employees. If employees are likely to take sickness absence from work, it is most likely to be short-term and due to acute health problems. Sickness presenteeism is a recurrent theme in this work, predominantly relating to presenting at work with acute illness requiring rest. These acute episodes spread easily to other employees and will take a longer time to recover from as cross infection and re-infection occur. Such cross infection may also spread outside the organisation depending upon the type of business. Some SMEs such as small hotels or catering outlets felt that it was impossible to manage acute illness when they are at their busiest, such as Christmas. This resulted in staff presenting at work when sick. The problem of presenteeism is that it has a stronger negative impact on performance than absenteeism and is harder to see, measure and manage. ³⁵ It is also a relatively little explored area of work.

The issue of authentic sickness and absence was raised across different organisations relating to perceptions about what was ‘real’ or ‘genuine’ illness. It seems that these are considered as being authentic if they are presented as physical symptoms. Thereby, people presented at work with acute illness, which potentially can spread, transmitted to other employees. The impact on productivity as employees recognise that their sickness absence has implications for their fellow colleagues, in terms of workload and working hours, is highlighted and correlates with the literature.^17–19 This study has explored the health and well-being needs of a sample of SMEs in Greater Manchester. It has highlighted that smaller and in particular micro businesses feel the effects of sickness, presenteeism and sickness absence more acutely than medium-sized businesses. This is significant for those in public health and those in other organisations that seek to support SMEs through these economic challenges. The provision of preventative services in the workplace such as flu vaccines (available on site and possibly at low cost or free of charge) may potentially influence the management of acute sickness, presenteeism and subsequently productivity for micro and smaller businesses.

SMEs face considerable challenges in the current economic climate. ² These challenges can mean that they fail to appreciate the wealth of health and well-being programmes that are available to them. Understanding these challenges and sometimes providing what can be considered as a ‘quick fix’ approach, such as flu immunisations, may go some way to understanding how public health can support SMEs workplace health.