Workplace health: management practices

This guideline covers how to improve the health and wellbeing of employees, with a focus on organisational culture and the role of line managers.

# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

# Organisational commitment
These recommendations are for employers, senior leadership and managers, human resource teams and all those with a remit for workplace health.
Make health and wellbeing a core priority for the top management of the organisation. Value the strategic importance and benefits of a healthy workplace. Employers should encourage a consistent, positive approach to all employees' health and wellbeing. 
Establish the business case for ensuring employees' health and wellbeing. Make clear the link between employees' health and wellbeing and improved productivity. 
Ensure all managers in the organisation, including directors and board members, are committed to the health and wellbeing of their workforce and act as good role models. 
Incorporate health and wellbeing in all relevant corporate policies and communications. For example, by ensuring employees work reasonable hours and have regular breaks. 
Make communication clear to ensure that employees have realistic expectations of what's possible, practical and affordable. 
Be aware that a return to work from sickness does not necessarily indicate that an employee's health and wellbeing has improved. When developing return to work polices, take into account that aggressive return to work procedures can encourage presenteeism to the detriment of the organisation. 
Recruit managers who have the positive leadership traits associated with improved employee health and wellbeing. These traits include being open and approachable and encouraging new ideas. 
Ensure health and wellbeing policies are included in any induction, training and development programmes for new staff. 
Have a proactive and visible commitment to health and safety and its role in improving the health and wellbeing of employees, that is, view health and safety as part of the culture of a caring and supportive employer  not only a statutory requirement. 

# Physical work environment
These recommendations are for employers, senior leadership and managers, human resource teams and all those with a remit for workplace health.
Develop and implement workplace policies and procedures to reflect statutory requirements and existing best practice (for example, manual handling and display screen equipment). 
Ensure all facilities and equipment are clean, safe, well maintained and of a good standard. 

# Mental wellbeing at work
These recommendations are for employers, senior leadership and managers, human resource teams and all those with a remit for workplace health.
Create a supportive environment that enables employees to be proactive when and if possible to protect and enhance their own health and wellbeing. 
Develop policies to support the workplace culture such as respect for worklife balance. For example, in relation to stress organisations could refer to the principles of the Health and Safety Executive's Management Standards for work related stress. These cover the following 6 aspects of work and the process for assessing and managing these:
demands (workload, work patterns and work environment)
control (how much say the employee has in the way they do their work)
support (from the organisation, line manager and colleagues)
relationships (promoting positive working to avoid conflict and dealing with unacceptable behaviour)
role (if employees understand their role within the organisation and whether the organisation ensures that they do not have conflicting roles)
change (how change is managed and communicated in the organisation). 

# Fairness and justice
These recommendations are for employers, senior leadership and managers, human resource teams and all those with a remit for workplace health.
Ensure any unfair treatment of employees is addressed as a matter of priority. 
Ensure line managers know how to direct employees to support if the employee feels that they are being treated unfairly. 
Offer older employees the same opportunities (including those identified in NICE's guideline on mental wellbeing at work) as younger employees. 
Treat each employee as an individual and avoid making stereotypical assumptions. For example, don't assume that an older employee may find learning new tasks difficult or that younger employees are less dependable. 

# Participation and trust
These recommendations are for employers, senior leadership and managers, human resource teams and all those with a remit for the workplace.
Ensure employees feel valued and trusted by the organisation by:
-ffering support and training to help them feel competent
promoting team working and a sense of community. 
Encourage employees to have a voice in the organisation, and actively seek their contribution in decisionmaking through staff engagement forums and (for larger organisations) by anonymous staff surveys. 
Value and acknowledge employees' contribution across the organisation. If practical, act on their input and explain why this action was taken. If employees' contributions are not acted on, then clearly explain the decision. 
Encourage employees to engage with trade unions, professional bodies and employee organisations whenever possible. 

# Senior leadership
These recommendations are for senior managers, employers and those with a leadership responsibility in workplace health.
Provide consistent leadership from the top, ensuring the organisation actively supports a positive approach to employee health and wellbeing and that policies and procedures are in place and are implemented. This should be part of the everyday running of the organisation, as well as being integrated in management performance reviews, organisational goals and objectives. 
Consider helping employees to access screening and other health services to which they are entitled. This could include providing information about services such as cervical screening and eye tests and allowing time off to attend appointments. 
Provide support to ensure workplace policies and interventions for health and wellbeing are implemented for line managers, so that they in turn can support the employees they manage. 
Ensure line managers are aware that supporting employee health and wellbeing is a central part of their role, for example by including it in line managers' job descriptions and emphasising it during recruitment. 
Display the positive leadership behaviours that are asked of line managers, such as spending time with people at all levels in the organisation and talking with employees. 
Act as a role model for leadership and proactively challenge behaviour and actions that may adversely affect employee health and wellbeing. 

# Role of line managers
These recommendations are for employers, senior leadership and managers, human resource teams, and all those with a remit for workplace health.
Recognise and support the key role that line managers have as the primary representative of the organisation and seek their input. Use line managers as a 2way communication channel between the employee and organisation, and to encourage staff to be motivated and committed to the organisation. Regularly seek line managers' views on staff morale and staffing and human resource issues. 
Acknowledge that line managers have an important role in protecting and improving the health and wellbeing of employees through involvement in job design, person specifications and performance reviews. Give line managers adequate time, training and resources to ensure they balance the aims of the organisation with concern for the health and wellbeing of employees. 

# Leadership style of line managers
Adopt a positive leadership style that includes:
encouraging creativity, new ideas and exploring new ways of doing things and opportunities to learn
-ffering help and encouragement to each employee to build a supportive relationship; acting as a mentor or coach; being open and approachable to ensure that employees feel free to share ideas; recognising the contribution of each employee
having a clear vision which can be explained and made relevant to employees at all levels; ensuring employees share the same motivation to fulfil their goals
becoming role models who are trusted and respected by employees
providing a sense of meaning and challenge, and building a spirit of teamwork and commitment. 
Use the following approaches:
consult regularly on daily procedures and problems
promote employee engagement and communication
recognise and praise good performance
work with employees to produce and agree employees' personal development plans
be proactive in identifying and addressing issues and concerns early, and take preventive action at the earliest opportunity, identifying sources of internal and external support. 
Avoid negative behaviour such as:
detachment from colleagues and ignoring employees' suggestions
failure to monitor and manage employees as a group
showing no interest in employees' ideas and projects
feeling threatened by competent employees
being guarded in communications, such as withholding information from colleagues and not keeping them fully informed. 

# Training
These recommendations are for employers, senior leadership and managers, executive teams, human resource teams, and all those with a remit for training.
Ensure line managers receive training in:
effective leadership (see section 1.8)
the importance of maintaining people's health and wellbeing at work and what this entails
the effect of health and wellbeing on improved organisational performance
keeping up to date with changes in the legal obligations and official advice to employers
the implications of organisational change and how to manage it
communication skills, including how to have difficult conversations with employees
developing people's skills and resolving disputes
how to support employees by agreeing relevant and realistic targets
how to recognise when someone may need support (for example, because of problems achieving a worklife balance, demands of home life or unfair treatment at work) and awareness of the services they could be directed to
how to use stress risk assessment to identify and deal with sources of stress, as well as develop workplace solutions to reduce this risk
the internal and external causes of stress, such as excessive workload, financial worries, workhome conflict or family issues
how to give advice to employees about further support for stress both in and outside the workplace
equality and diversity training on employee health and wellbeing
how to manage sickness absence in line with NICE's guideline on workplace health: long-term sickness absence and capability to work. 
Ensure the above skills and behaviours are set out in any documents outlining the skills and knowledge line managers need, and in their performance indicators. 
Ensure line managers receive training to improve their awareness of mental health and wellbeing issues. This includes increasing their awareness of how they can affect the psychological wellbeing of employees. It also includes equipping managers to identify when someone may have a mental health problem, for example learning to identify signs and symptoms and looking for changes in behaviour and performance. Ensure line managers can give employees advice on where to get further support. 
Line managers should offer older employees the same training and development opportunities as other employees. 
Offer or support older employees, in the same way as other employees, to undertake training if their job role changes. 
Tailor training programmes to meet employees' individual needs, learning style and ability. This could include providing:
a training needs analysis
workbased, practical onthejob training
mentoring or onetoone sessions
-pportunities for reflection. 
Encourage and help employees, including older employees, who have few qualifications, or who may have received education and training some years ago, to make the most of learning and development opportunities. This includes giving them the necessary time off for training. 

# Job design
These recommendations are for line managers.
Encourage employees to be involved in the design of their role to achieve a balance in the work demanded of them. Allow them to have a degree of control, appropriate to their role, over when and how work is completed. This should take into account the resources and support available. 
If possible, and within the needs of the organisation, be flexible about work scheduling, giving employees control and flexibility over their own time. 
When implementing flexible working, balance the needs of the business with the workloads and needs of other employees. 
Take into account the effect on physical health when designing jobs. This could include, for example, ergonomic reviews, and giving advice on posture and on moving and handling physical loads. Design jobs to promote and improve the physical health of employees by, for example, helping people to be physically active in their working day. See NICE's guideline on physical activity in the workplace. 
Address the needs of older employees as part of a broad diversity policy to support retention of older employees. This should include recognising key life stages and life events and taking into account that caring responsibilities may change as people age. This policy could include:
providing timely and appropriate support, for example, flexible working policies or carer's leave
communicating working time options and eligibility clearly and without jargon, and providing information on the financial implications of flexible working if relevant
planning and resourcing the policy effectively, including early liaison between HR and pensions fund staff if appropriate. 
For each employee, identify and address issues affecting their health, wellbeing and ability to do their job. This includes the impact of shift work, and in particular of night working. 
Consider delivering a workplace health promotion programme incorporating both physical activity and diet. See our topic pages on diet, nutrition and obesity and physical activity. 

# Monitoring and evaluation
These recommendations are for employers, senior leadership and managers, human resource teams, and all those with a remit for workplace health.
Regularly monitor and evaluate the effect of new activities, policies, organisational change or recommendations on employee health and wellbeing and identify and address any gaps. 
Ensure managers regularly review their own progress in promoting workplace health and wellbeing and acknowledge any gaps in their competencies. Organisations should support line managers in this activity. 
Identify and use reliable and validated tools to monitor impact. 
Give line managers a role in monitoring impact. 

# Terms used in this guideline

## Health and wellbeing
Health relates to a person's physical or mental condition. Wellbeing is the subjective state of being healthy, happy, contented, comfortable and satisfied with one's quality of life.

## Leadership
The action of leading a group of people or an organisation, or the ability to do this. The ability of an organisation's management to make sound decisions and inspire others to perform well.

## Line manager
A person with direct managerial responsibility for an employee.

## Microorganisation
An organisation employing fewer than 10 people.

## Occupational health service
A service established either inhouse or externally to:
protect employees against health hazards from their work or working conditions
support the physical and mental wellbeing of employees
conduct medicals and monitor the health of new and existing employees
help organisations manage short and longterm sickness absence.

## Presenteeism
Inappropriately continuing to go to work despite health problems. It also describes someone's attendance at work without performing all of their usual tasks (regardless of the reason). When employees feel the need to attend work although they are not functioning fully it can result in losses in productivity. Presenteeism can also make health problems worse.

## Vocational rehabilitation
Helping people who are finding it difficult to obtain, stay in or return to work because of a physical or mental impairment.# Recommendations for research

# Recommendations for research: effectiveness
The guideline committees made the following recommendations for research.
The Public Health Advisory Committee E recommends that the following research questions should be addressed. It notes that 'effectiveness' in this context relates not only to the size of the effect, but also to cost effectiveness and duration of effect. It also takes into account any harmful or negative side effects.
All the research should aim to identify differences in effectiveness among groups, based on characteristics such as socioeconomic status, age, gender, ethnicity, size and type of employer and whether workers were paid or unpaid.

## How can the implementation of the recommendations made in this guideline be evaluated?
This research should be developed in collaboration (or coproduced) with those likely to use or be offered the interventions studied, that is, line managers and employees. More UK intervention studies are needed with line managers in a range of organisations to answer the following questions:
What is the effect of including criteria on positive leadership style (associated with employee health and wellbeing) in line manager selection?
What is the effect of different leadership styles on employee health and wellbeing?
What is the effect of training line managers in positive leadership behaviours?
What is the role of the organisational culture and context in supporting line managers and, in turn, their employees?
What is the effect of changes to job design and working practices (such as introducing more employee autonomy and control)?
What is the effect of intervention length (such as training of line managers) and the gradual change in intervention effect? Such studies would help in economic modelling and in assessing the length of time over which the cost of interventions should be discounted in economic analyses.
What is the role of occupational health, human resources and health and safety advisers in supporting line managers in promoting workplace health and wellbeing?
How might these functions work effectively, both together and separately, to improve health and wellbeing at work?
What are the barriers and facilitators to implementing interventions or policies to promote the role of line managers in improving employee health and wellbeing?

## . How can outcome measures relating to workplace health and wellbeing be measured?
Research funding bodies such as the National Institute for Health Research or Economic and Social Research Council should ensure clear outcome measures relating to workplace wellbeing, work retention, workplace absence, workplace performance and productivity, return to work and work retention are included in all the research they fund. This will ensure that all intervention research examines the effect on people's working lives and their health and wellbeing.

## . How can the effectiveness of workplace health policies and programmes be measured?
Further research studies need at least 3 measurement points:
before the intervention takes place
after the intervention has finished, to measure immediate effect
a later point, such as 12 to 18 months from the start, to measure longerterm effect.
The design of studies should also consider the effects of staged interventions (such as training line managers in new practices, assessing uptake and implementation, and its effect on the workplace). How effective are methods for synthesising such evidence, including relevant equalities characteristics? Finally, there is a need to fund more longitudinal studies to identify cause and effect relationships.

## . How can the design and reporting of the outcomes used in intervention studies be improved, so researchers can identify 'active ingredients'? Which validated tools are effective at consistently measuring success, especially in relation to health and wellbeing, performance, productivity and in economic terms?
Research studies should collect both subjective and objective measureable outcomes of wellbeing. This will help organisations to make a business case to invest in policies and measures to improve the health and wellbeing of their employees.
More detail identified during development of this guideline is provided in gaps in the evidence.

# Recommendations for research: older employees
The Public Health Advisory Committee D recommends that the following research questions should be addressed.

## Maintaining and improving the health and wellbeing of older employees
What are the most effective and costeffective interventions to maintain and improve the health and wellbeing of older employees?
Demographic changes, and changes to the state pension age, mean the proportion of older employees in the workforce is likely to continue to increase. Productivity depends on the workforce being in good health, and a person's health will affect their ability to stay in work and continue earning an income. However, older employees may wish to remain in work for a variety for reasons other than financial. Continuing to work can have both social and health benefits for older people. So there is a need to further understand what can help to maintain and improve outcomes in this group from a health and wellbeing perspective.

## Helping older employees stay in work
What are the most effective and costeffective interventions to help older employees stay in or reenter work? For example, to overcome the problems of a change in job specification?
Older people are more likely to be unemployed or economically inactive than younger people and tend to find getting back into work after an absence more difficult. It is important to ensure they can stay economically active if possible as changes in the state pension age mean many people will need to work in their later years.

## Helping older employees plan and prepare for retirement
What are the most effective and costeffective interventions to help older employees plan and prepare for retirement?
It is important that older employees leave the workforce at the time and in the way that suits them, because a lack of control (this could be perceived or real) over these decisions may have an impact on their wellbeing.

## Challenging stereotypes and changing attitudes towards older employees
What are the most effective and costeffective interventions to challenge stereotypes and change employers' and workforce attitudes towards older employees?
Negative attitudes and stereotyping have led to some older people retiring before they wanted to. Changing attitudes and reducing stereotyping may result in people working for longer, with all the associated benefits for them and society. Reducing negative attitudes may also improve mental health and wellbeing and reduce distress arising from exposure to negative stereotyping.# Committee discussion
For an explanation of the evidence statement numbering, see the evidence reviews section.
The committee (Public Health Advisory Committee E) was mindful that selfemployed people are not included in this guideline. However, many selfemployed people are also line managed, for example on a fixedterm contract or for a particular project. The guideline applies to the line management of contract, temporary and agency employees where appropriate.
The committee acknowledged that the relationship between line management and employee wellbeing is complex and can vary by occupation, organisation size, sector and a number of other factors.
The committee acknowledged the different cultures and working practices between organisations. These can vary widely by organisation size, from large multinational organisations, small and mediumsized enterprises to micro-organisations. These differences will affect how recommendations are implemented.
The evidence reviews showed that studies conducted in different countries often yielded similar results. The applicability of findings to the UK were taken into account.
All the findings showed a positive association between all interventions and employee health and wellbeing. Causation could not be determined by the studies included in the qualitative reviews.
The committee considered whether employers should be required to promote 'traditional' workplace health interventions such as exercise, healthy diet and stopping smoking. However the committee felt it was not appropriate to mandate employers to do this.
The consequences of implementing workplace health policies or interventions need careful consideration because they may have unexpected (and often undesirable) knockon effects on other employees. The core principle of workplace health policies or interventions is to 'cause no harm'.
The committee acknowledged that people management is as important as task management. The committee noted that organisations committed to workplace health and wellbeing consult employees and perform needs assessments. The committee also noted the importance of health and wellbeing as a consideration during business planning and any organisational change, given the possible impact this may have on all staff.
The committee agreed the importance of good management and acknowledged that a number of leadership styles are discussed widely in the literature. The evidence reviews for the guideline reported findings for both positive and negative leadership styles including transformational, authentic and selfcentred leadership. Although the committee has recommended the need for line managers to develop a positive leadership style, it does not endorse any particular positive leadership style.
The committee recognised that in most organisations promotion opportunities normally involve increased management responsibilities. However, some people with excellent technical skills do not have (or do not want to develop) the necessary 'people skills' to line manage. The committee noted that these people may benefit from alternative promotion and development opportunities.
The committee recognised that line managers, like the employees they manage, may experience life crisis events such as grief or bereavement, relationship problems or financial difficulties. The committee noted that at such times line managers will seek and receive staff support services that are available to all employees. Furthermore, the committee noted that line managers could also seek support for themselves with any mental health or physical health issues they are experiencing.
The legal obligations of employers were also acknowledged, such as health and safety responsibilities, sight tests, supporting those who are visually impaired or otherwise disabled and providing safety equipment. Employers may find it useful to use Health and Safety Executive codes of practice and Equality and Human Rights Commission codes of practice and technical guidance.
The committee noted the important work of the Advisory Conciliation and Arbitration Service (ACAS) in helping prevent and resolve workplace problems. Members agreed that employers may find it useful to use ACAS codes of practice and guidance.
Most of the studies identified in the evidence reviews report shortterm outcomes. The committee felt that a longterm focus is also needed when commissioning and planning further research. There is a need for more longitudinal studies to investigate sustainable effects over longer followup periods.
The committee recognised that there was a need for a national database on the effect of new activities, policies and organisational change on health and wellbeing. National recommendations of this kind are outside the scope of this guideline. However, the committee discussed that it would be useful for employers if such a database included productivity and business outcomes, cost information and the general and economic benefits of providing a healthy workplace. It also noted that there was a need for qualitative data and evidence on what works for whom and when. The committee also discussed the fact that employers, practitioners and researchers on workplace health may provide a useful contribution to this nationwide database.

# Economic evaluation
Some key benefits of improving the health of employees through improved workplace practices are hard to measure quantitatively. These benefits include a feeling of increased safety and satisfaction, greater loyalty, and improved societal reputation for employers, and are associated with increased productivity of workers. There is consistent evidence that relatively small investment in line manager training (and its effects on their attitudes and those of their employees) can lead to worthwhile improvements in worker satisfaction, which in turn are linked to gains in productivity for the organisation. The modelling done for this topic shows that these productivity increases will usually be at least as large as the benefits of reducing absenteeism, presenteeism and employee turnover, and may be many times larger. However, it may take some time to recoup the initial investment.
The committee agreed that an emphasis on employee health and wellbeing is equally important during a recession or financial crisis, as in times of economic growth. A focus on health and wellbeing can sustain and develop a strong workforce for the future.

# Committee discussion about older employees
The committee (Public Health Advisory Committee D) agreed that recommendations covering older employees should be considered as part of a wider approach to promoting all employees' health and wellbeing. They were therefore incorporated into the existing public health guideline on this topic. This would simplify and support the process of implementing both sets of recommendations.
The committee noted that workplace policies and practices could also affect other groups such as people with disabilities or minority ethnic groups. Although actions could be taken to address the needs of these groups, the aim of extending this guideline was to incorporate recommendations on older employees in line with the referral from the Department of Health.
The committee noted that older people are more likely to be unemployed or economically inactive than younger people, and tend to find getting back into work after absence more difficult.
Unpaid workers are included in the recommendations because the committee was aware of the many benefits (to volunteers, organisations and wider society) gained from older people's participation in unpaid work. The committee's view was that much of the evidence is likely to be applicable to these volunteers.
Changes to workplace health and safety and other relevant legislation are not part of the guideline scope. The committee had hoped to make recommendations to help increase employers' awareness of the legislation and support its implementation, in particular related to the needs of older employees. Although this is out of scope, members recognised and reflected on its importance in their discussions.
Committee members noted that NICE's guideline on alcohol-use disorders: prevention makes only limited reference to the workplace. This was because there was only limited evidence about alcohol interventions at work at the time it was published. The committee noted that the workplace is now recognised as an important setting for delivering brief advice on alcohol. Making general health promotion recommendations is outside the scope of this work, but the committee wanted to recognise its importance here.

## Issues for older employees
The committee agreed that the benefits of working can extend beyond financial remuneration. Actively participating and making a worthwhile contribution at work can improve health and wellbeing. Working (including volunteering) can also be an important way of socialising and making friends.
But members also agreed that not everyone benefits from work. For example, work that makes excessive physical and mental demands on a person can be detrimental to their health and wellbeing. The committee recognised this by recommending offering retraining opportunities (recommendation 1.9.5) to enable them to continue working if their job role changes.
The committee discussed changes to the state pension age and the abolition of the default retirement age, including the potential health implications of a later retirement. But the effects of these changes have not yet been reported in the published literature. Lack of evidence meant that interventions on planning and preparation for retirement could not be included. They also noted that selfemployment and the use of zerohours contracts (in which the employer is not obliged to provide any minimum working hours, and the worker is not obliged to accept any work offered) were not considered by the published literature.
The committee noted that as people age their caring responsibilities change, and this is likely to become more common as more people survive into older age. Some employees may be caring for their children and their parents at the same time, while others may have caring responsibilities for their grandchildren. Bereavement also has a significant impact, particularly if it involves loss of a partner. As the working age extends it may become more likely that people will experience bereavement while they are still working.
The committee reflected this need in recommendation 1.10.5. The evidence for this recommendation included 13 studies  including surveys and qualitative studies on older workers, which covered attachment to work, and factors that help and hinder flexible working for older employees. There was also evidence from a range of other studies  from surveys, qualitative data and mixed methods approaches on flexible working and on retirement decisions and financial planning . The committee recognised the limitations of the study types in terms of bias. But it agreed that the results were in line with its own experience and expert consensus. It also agreed that making recommendations about these issues was important to support older employees in the workplace.

## Stereotypical assumptions about older employees
The committee discussed the need to avoid stereotypical assumptions about older employees, such as assuming that they are unwilling to change or unwilling to learn (recommendations 1.4.3 and 1.4.4; ). That is because such assumptions risk marginalising this group, and could prevent employers from making the best use of their potential.
This is the case even when the assumptions are positive (for example, that older people may be more reliable and loyal). Making such assumptions may imply, for example, that younger employees are less reliable and less loyal.

## Workplace health interventions for older employees
The committee noted that poor health can have a direct impact on a person's ability to work. Other factors related to poor health, such as the time needed for health appointments, and the need to take medication at work or to manage any adverse effects of treatment, will also have an impact. The committee agreed by consensus that providing health interventions at work, such as flu vaccinations for the over65s, may be helpful for employees who find it difficult to attend health appointments during the day, although this would only cover a small proportion of the workforce. However, the committee decided that offering a general workplace health promotion service may not increase uptake of these services in older employees.
The committee agreed on the need to raise awareness of healthrelated issues and recommend signposting to relevant services (as in recommendation 1.6.2), such as free eye tests for people over 60. However, it noted that some services are also available to younger age groups and it would be important to ensure that all employees are helped to access appropriate services.
The committee considered comments on the importance of communication issues relating to sight and hearing loss. These can have a significant impact on people, both at work and in other areas of their lives. However, no evidence was found relating specifically to sight or hearing issues. The committee noted that equalities legislation requires employers to make reasonable adjustments to the workplace to accommodate the needs of people with visual impairments. However, the committee felt it was not necessary to recommend compliance with a legal requirement.
The committee looked at recovery from shift work and the role of physical activity and diet programmes in supporting recovery. The evidence base identified by NICE's commissioned review was limited. Evidence supported the committee's view of the potential impact of shift working on health . Weak evidence from 1 poor quality () beforeandafter study was found on rotation of shift and its impact on older employees . The committee felt that considering the impact of shift work in the recommendations was warranted (recommendation 1.10.6), although the evidence did not allow a recommendation to be made about the type or frequency of shift patterns specific to the needs of older workers. Evidence from 1 moderate quality (+) randomised controlled trial (RCT) showed positive outcomes in mental health and decreased daily work strain from a physical activity intervention. Another moderate quality (+) RCT of a worksite vitality intervention (comprising exercise and yoga sessions, free fruit and visits from a coach) had a beneficial effect on recovery after work in employees aged over 45 years . The committee recognised the limitations of this evidence but considered it plausible that physical activity and improved nutrition could have a beneficial effect on recovery, and may also have other broader health outcomes (recommendation 1.10.7).

## The evidence for older employees
The reviews examined evidence relating to employees aged over 50. Two reviews looked at the effectiveness of interventions and were limited to evidence published since 2005, and to evidence from OECD (Organisation for Economic Cooperation and Development) countries. They excluded older employees with preexisting health conditions. Studies were included that were aimed at employees aged over 50 or addressed entire workforces where at least 51% of employees were aged over 50.
Full details of inclusion and exclusion criteria are in the evidence reviews.
Little evidence was found on the effectiveness and cost effectiveness of interventions for older employees that aim to:
improve their health and wellbeing
extend their working lives
help them prepare and plan for retirement.
A third review (of qualitative research) was restricted to the UK, Australia and New Zealand.
Evidence about the general workforce is likely to be more extensive, but the referral from the Department of Health was specific to older employees and the literature search reflected this.
The evidence identified focused on older employees. It did not identify any headtohead comparisons between the needs of older and younger employees so the committee couldn't determine whether different interventions are needed for older and younger employees. The committee recognised that the evidence identified may apply equally to younger age groups, and have developed the recommendations to recognise this where possible.

## Economic modelling
Economic modelling was carried out from an employer's perspective because they will be paying for the interventions to maintain and improve older employees' health and wellbeing. Because every organisation is different, the committee wanted the modelling to take the form of a cost calculator that could be used by individual organisations.
The cost calculator assumes that employers are concerned only with profits. This is not necessarily the case, so it is likely to underestimate the range of potential benefits to the organisation (such as loyalty and active participation in reaching organisational goals).
To estimate whether an intervention is worthwhile, the organisation inputs its details, including number of employees, annual staff turnover, absentee rate and the gross cost of the intervention. The assumptions made can be modified to model 'what if' scenarios. The calculator then estimates the net cost of the intervention.
The basic cost calculator does not include healthcare costs, but users may add this aspect. The model assumes the intervention will reduce the sickness absence rate.
Employers will need to use their own judgement about how well the assumptions in the model reflect their own circumstances.
In addition, the cost calculator does not take account of any positive or negative effects on third parties. For example, it does not calculate any potential reduction in road collisions, third party injuries or hospital care needed as a result of interventions to improve the performance of older employees who drive as part of their work. 

# Evidence reviews
Details of the evidence discussed are in the evidence reviews.
The evidence statements are short summaries of evidence, in a review, report or paper (provided by an expert in the topic area). Each statement has a short code indicating which document the evidence has come from.
Evidence statement (ES) number 1.1 indicates that the linked statement is numbered 1 in review 1. ES 2.1 indicates that the linked statement is numbered 1 in review 2. ES 2.1 (1) indicates that the linked statement is numbered 1 in review 2 and relates to key question 1. EP1 indicates that expert paper 'Ipswich Building Society' is linked to a recommendation. EP2 indicates that expert paper 'People matter' is linked. EP3 indicates that expert paper 'Workplace practices to improve health' is linked. EP4 indicates that expert paper 'Expert testimony: Dr Maria KaranikaMurray' is linked. EP5 indicates that expert paper 'Expert testimony: Sarah Page, Prospect Union' is linked. EP6 indicates that expert paper 'Health in older workers: an introduction' is linked. EP7 indicates that expert paper 'Some evidence on impact of Age Management and Work Ability Programmes' is linked. EP8 indicates that expert paper 'Extending working life, pensions & retirement planning' is linked. EP9 indicates that expert paper 'Employers' attitudes and practices towards older workers. Policies and approaches to combat barriers for older employees and support extended working lives: an international perspective' is linked. EP10 indicates that expert paper 'Work Ability model and index' is linked. EP11 indicates that expert paper 'Extended and extending working lives: your experience of the health and care sector. An international perspective' is linked. EP12 indicates that expert paper 'Healthy workplaces group (Age Action Alliance) and your work with the Employers Network for Equality and Inclusion'.
If a recommendation is not directly taken from the evidence statements, but is inferred from the evidence, this is indicated by IDE (inference derived from the evidence).
The evidence statements from 6 reviews are provided by external contractors.
Section 1.1: ES1.1, ES1.3, ES3.2d; EP1, EP4; IDE; modelling report: economic analysis of workplace policy and management practices to improve the health of employees. 
Section 1.2: ES3.2d; EP2, EP4, EP5; IDE 
Section 1.3: ES1.1, ES2.1, ES3.1c, ES3.2b, ES3.2c, ES3.4; EP1, EP4, EP5; IDE 
Section 1.4: ES3.3; EP4, EP5; IDE 
Section 1.4: ES6.2a, ES6.2c; EP9, EP11; IDE 
Section 1.5: ES2.4, ES3.1d, ES3.2c, ES3.3; EP2, EP4; IDE 
Section 1.6: ES3.1a, ES3.1e, ES3.2a, ES3.2b, ES3.2c, ES3.2e, ES3.2f; EP1, EP2, EP4, EP5; IDE 
Section 1.6: IDE 
Section 1.7: ES1.1, ES2.4, ES3.1a, ES3.1d; EP4, EP5; IDE 
Section 1.8: ES2.4, ES3.2a, ES3.2b, ES3.2c, ES3.2e, ES3.2f, 3.5; EP2, EP4; IDE 
Section 1.9: ES1.1, ES2.1, ES3.1c; EP5; IDE 
Section 1.9: ES6.2a, ES6.2c, ES6.3; EP11; IDE 
Section 1.10: ES3.1c, ES3.1d, ES3.2c, ES3.4; EP1, EP2, EP4, EP5; IDE 
Section 1.10: ES4.1, ES4.2, ES4.6, ES6.1a, ES6.1b, ES6.2a, ES6.2c, ES6.3, ES6.4a, ES6.4b, ES6.4c, ES6.8c; EP10; IDE 
Section 1.11: EP1, EP3; IDE 

# Gaps in the evidence
Both committees identified a number of gaps in the evidence related to the programmes under examination based on an assessment of the evidence and stakeholder comments. The gaps relating to the original workplace guideline are set out below numbered 15, followed by the gaps relating to older employees numbered 615.
. There were only 5 UK studies reported in the 3 evidence reviews undertaken for this guideline. There is therefore a need for more research in the UK. Furthermore, no costeffectiveness studies were found that could answer the research questions. So there is also a need for more economic and costeffectiveness data. More research is needed on how much training, and what kind of training, line managers should have to reduce worker absence and staff turnover cost effectively. There is also a need to identify the extent to which interventions designed to improve the wellbeing of employees can cost effectively increase productivity.
(Source: evidence reviews 1, 2, 3 and cost effectiveness review)
. More evidence is needed from small and mediumsized organisations.
(Source: evidence reviews 1, 2 and 3)
. No studies were found on the line management of unpaid workers such as volunteers and interns.
(Source: evidence reviews 1, 2 and 3)
. More research is needed on the effective contribution of occupational health, human resources and health and safety to supporting line managers in promoting workplace health and wellbeing.
(Source: evidence reviews 1, 2 and 3)
. There is a need for more accurate and detailed reporting of study methods to encourage transparency, ensure studies can be replicated and assess longterm impact. Studies need to report what does not work as well as what works. There is also a need for journals to have editorial policies that invite and publish reports of negative, inconclusive or positive effects. The suppression of negative results can bias study effectiveness.
(Source: evidence reviews 1, 2 and 3)
. There is a need for evidence on how different work conditions affect perceived workplace equity for older employees compared with the whole workforce.
(Source: evidence review 6)
. There is a need for evidence on how workplace interventions for older employees affect health inequalities.
(Source: evidence reviews 4, 5 and 6)
. There is a need for evidence on the effectiveness and cost effectiveness of interventions aiming to improve and maintain the health and wellbeing of older employees.
(Source: evidence review 4)
. There is a need for evidence on the effectiveness and cost effectiveness of interventions to help older employees remain in work. For example, the impact of a change in job specification on retention.
(Source: evidence review 4)
. There is a need for evidence on the effectiveness and cost effectiveness of interventions to help older employees plan and prepare for retirement.
(Source: evidence reviews 4, 5 and 6)
. There is a need for evidence on the options for work, retirement and pensions on offer and the impact of these options on a person's decision whether or not to stay on at work. This includes providing flexible and parttime work, or a change in job role.
(Source: evidence reviews 4, 5 and 6)
. There is a need for evidence on the effectiveness and cost effectiveness of interventions to challenge stereotypes and change employer and general workforce attitudes to older employees.
(Source: evidence reviews 4 and 6, expert testimony 12)
. There is a need for evidence on the transferability of interventions to support older employees across employment sectors.
(Source: evidence review 6)
. There is a need for evidence on knowledge about and uptake of newer technologies by older employees.
(Source: evidence review 6)
. There is a need for evidence on the health benefits and risks of extending working life and how these may vary according to the nature of the work.
(Source: evidence reviews 5 and 6)
Both committees made recommendations for research that they believe will be a priority for developing future guidelines. These are listed in recommendations for research.# Context
There is strong evidence to show that work is generally good for people's physical and mental health and wellbeing (Is work good for your health and well-being? Department for Work and Pensions; Annual report of the Chief Medical Officer surveillance volume, 2012 Department of Health).
It meets important psychosocial needs in societies in which employment is the norm and is central to someone's identity, social role and status ('Is work good for your health and wellbeing?'). Work can also reverse the illhealth effects of unemployment.
However, these benefits do depend on the type of work involved (Good work and our times, Good Work Commission). There is also a positive association between wellbeing, job satisfaction and an employee's job performance. Many studies have also shown a relationship between supportive supervision and job satisfaction. These findings provide a strong case for employers to consider investing in the wellbeing of their employees on the basis of likely performance benefits (Does worker wellbeing affect workplace performance? Department for Business, Innovation & Skills).
During 2013/14, 1.2 million working people had a workrelated illness. Half a million of these were new illnesses (Health and Safety Statistics Annual report for Great Britain 2013/14, Health and Safety Executive). Workrelated illness and workplace injury led to the loss of an estimated 28.2 million working days in 2013/14. Injuries and new cases of ill health resulting largely from current working conditions cost society an estimated 14.2 billion in 2012/13 (based on 2012 prices).
People's health can be damaged at work by, for example:
physical hazards
physically demanding or dangerous tasks
long or irregular working hours or shift work
tasks that encourage a poor posture or repetitive injury
tasks that mean someone is sedentary for prolonged periods of time.
Lack of control over the work (including a lack of opportunity to take part in decisionmaking), conflicts in workplace hierarchies, and covert or overt discrimination can also affect health.
All these factors are most prevalent among people who are in jobs that are low paid, unsafe and insecure (Fair society, healthy lives, The Marmot review). On the other hand, the Good Work Commission in 'Good work and our times', noted that 'employees and employers alike recognise that these days guaranteeing job security is unrealistic'. It also pointed out that employers have a role in ensuring people are equipped with transferable skills that will be an asset in the future.
The World Health Organization has highlighted the importance of ensuring the culture of an organisation promotes health and wellbeing (Healthy workplaces: a model for action). A 'healthy' culture, for example, would include having fully implemented policies on:
dignity and respect
preventing harassment and bullying
preventing gender discrimination
tolerance for ethnic or religious diversity
encouraging healthy behaviours.
Good line management has also been linked with good health, wellbeing and improved performance (Working for a healthier tomorrow, Department for Work and Pensions).
Poorquality leadership, on the other hand, has been linked with stress, burnout and depression (Mental capital and wellbeing: making the most of ourselves in the 21st century, Government Office for Science). It can also affect how well employees relate to the organisation, their stress levels and the amount of time they spend on sick leave (See the, Affinity Health at Work final research phase project report on preventing stress: promoting positive manager behaviour phase 4: How do organisations implement the findings in practice?; funded by Health and Safety Executive, Chartered Institute of Personnel and Development and Investors in People.).
A Confederation of British Industry (CBI) report highlighted the importance of providing adequate training for line managers to help them support employees with a health condition to remain at work (Getting better: workplace health as a business issue). Furthermore, the Workplace Wellbeing Charter (which provides an opportunity for employers to demonstrate their commitment to the health and wellbeing of their workforce) recognises the importance of line managers in their standards.
Evidence suggests that people going to work while they are sick ('presenteeism') is a more costly problem for employers than absenteeism (Sainsbury Centre for Mental Health policy paper 8 on mental health at work: developing the business case). This is partly because it is more likely to occur among higherpaid employees.
'Presenteeism' may be caused by the culture of an organisation or the nature of the work  or both (people may come to work when they are unwell because they don't want to let their team members down). It leads to poorer longerterm health outcomes (Working while ill as a risk factor for serious coronary events: the Whitehall II study Kivimaki et al. 2005; The future of health and wellbeing in the workplace Advisory, Conciliation and Arbitration Service). A study examining the prevalence of presenteeism in the UK found that nearly 60% of the sample reported presenteeism during a 3month period (Poor health but not absent: Prevalence, predictors and outcomes of presenteeism study Robertson et al. 2012.). The majority of participants (67%) indicated that the primary pressure to go to work while sick came from themselves. A substantial minority (20%) also indicated that their manager was a source of pressure.
The number of employed people aged 65 or over in the UK has more than doubled over the past 2 decades, from 425,000 in 1994 to almost 1.17 million in 2015. Furthermore, nearly 8.2 million people aged 5064 were also in employment in 2015 (Labour Market Statistics, June 2015, Office for National Statistics). The proportion of older employees is similar across all sectors (HSE horizon scanning intelligence group demographic study, Health and Safety Executive).
By 2020, it is predicted that older people will account for almost a third (32%) of the workingage population and half of the adult population (National Population Projections, 2012-based projections, Office for National Statistics). Increases in the state pension age may mean the proportion of this group continuing in employment increases further.
Older people who earn less tend to retire earlier than their middleincome peers, due to ill health and disability (Living in the 21st century: older people in England ELSA 2006  Institute for Fiscal Studies). They are more likely to have longterm health problems, some of which are attributable to lifestyle behaviours. They also have higher rates of nonwork related stress and mental health problems.
If people in this group are to work until 68, action is needed to raise their general level of health, reduce health inequalities ('Fair society, healthy lives') and offer a broader range of employment opportunities.
Over the next 10 years it is predicted that there will not be enough young people to fill the jobs available. So employers will become more reliant on older people (Managing a healthy ageing workforce: a national business imperative Chartered Institute of Personnel and Development).