The very earliest evidence – in the Western world – of a business taking the trouble to try to ease the lives of its workers is to be found in Minneapolis, Minnesota, US, where in 1917 the family-owned Northern States Power Company hired a social worker and established an in-house assistance programme to deal with what the paternalistic owners saw as the complex human concerns of their employees. This innovation was followed soon after by Macy’s department store in New York, which created a Department of Social Services. Its three-pronged role was to provide employees with information about the city’s health, recreational, and educational resources, step in with financial help if it was suspected that a worker’s accommodation situation required it and offer personal counselling to employees. By the 1930s, US factories were developing programmes to tackle what was politely known as occupational alcoholism – drinking on the job – which was affecting industrial productivity.
Much more recently, in England, the significance of employee assistance programmes (EAPs) was underlined in 2002 by a Court of Appeal judgement in a case involving a claim for workplace stress: “An employer who offers a confidential advice service, with referral to appropriate counselling or treatment services, is unlikely to be found in breach of duty.”
Common relocation concerns
There was a time when company assistance available for employees working overseas – people in the pre-Skype decades out of sight and often out of minds of a distant HQ – added up to a helping hand in an emergency: sudden illnesses, troubles with the local police perhaps, and lost passports. But the range of services now being provided for staff on secondment abroad has grown to become an all-embracing, comprehensive care package.
And it’s a package, says Stuart Leatherby, Chief Commercial Officer at Generali Global Health (GGH), that’s made available before an employee – and his or her partner and children – fly off to foreign parts. “People have a number of concerns when they’re going to be posted overseas,” he told ITIJ. “The first is wondering how they would acclimatise to the new position, the new culture, and the new environment, and that raises a myriad of questions: How am I going to be able to cope with that? Are there issues that might affect my health? What do I need to consider? There are things such as homesickness, anxiety and perhaps problems with assimilation. And they’re some of the reasons why we have an EAP specifically for the international environment, because it’s a different set of circumstances.
“Another question people will have about their posting is: What is the healthcare structure there like? If I am ill, where do I go? I might not have a medical facility around the corner. If people are in a very remote location – which can be the case in the gas and mining industries – they might find it very difficult to find a medical facility, which is one of the reasons we provide a remote doctor service. It’s important for them to know they can get access to a doctor and prescription medications. It’s also important for them to know what’s covered by a health system in the state they’re going to. Do they need cover for primary care consultations, for emergency treatment or outpatient service? Is there access to alternative medicine and, if so, does that have to be paid for? Is there any kind of state healthcare safety net or not? All of these things have to be thought about when people are looking at buying medical insurance or when their employer is providing it for them.”
It is incumbent a little bit on us to come up with some solutions that aren’t leaving the employer to always be thinking about every situation
At Aetna International, Vicky Dymoke, Marketing Director, Europe, tells ITIJ that the focus of the EAP industry has moved from the reactive to the proactive. “It’s shifted from risk management tools to wellbeing solutions. It means EAPs are no longer just there to support employees in moments of crisis – although they still cater for this – but also to provide proactive holistic mental health and wellbeing tools and services. Whether it’s access to coaching for emotional distress, marital issues or substance abuse, or being connected to training, support and online resources – such as AWARE, for mindfulness-based stress reduction, or digital therapeutics, such as myStrength – the service can be a great first line of defence. It’s vital when you consider that mental health is a huge issue affecting some 300 million people globally.
“Unfortunately, however, EAPs are frequently under-utilised. In an effort to address this, organisations are recognising that employee comfort levels and usage increases when this type of confidential solution is not portrayed as being linked to their workplace. Despite media attention and a huge effort to open up the conversation around mental health in the UK, there is still a lingering fear of employment discrimination around certain conditions, including stress, anxiety and depression … despite how common these conditions are. In some countries, this fear of stigma can be acute. It could be that, in the future, simply removing the word ‘employee’ from the package, resource or support helps to remove the perception that the employer receives knowledge of who is accessing the service, why and when.”
Mental health: cultural differences
Scott Madden, Head of Strategy at GeoBlue in the US, cites recent studies that have highlighted behavioural health as a growing concern, particularly among younger generations, and flags up its significance for companies providing EAP options: “Millennials make up 50 per cent of the US workforce today. Blue Cross Blue Shield published a report on the health of millennials, which said that of the top 10 health conditions impacting millennials, six are behavioural health conditions affecting mental health and emotional wellbeing.”
The issue of mental health is also picked up by Towergate’s Head of International, Sarah Dennis, who highlighted the cultural differences apparent around the world in terms of how mental health issues are diagnosed and treated: “Globally, mental health is a tricky subject because it’s not recognised in many countries and it can still be a taboo topic, making [related services] difficult to access in some countries. So, providing an EAP for employees abroad can be a lifeline for those suffering from stress, isolation or other issues. The best option is a global EAP supplier that offers a programme that fits no matter where you are in the world. Sometimes, just changing the phrase ‘mental health’ to ‘wellbeing programme’ can make all the difference.
“Having an EAP can provide a vital outlet for people working overseas who are feeling detached, isolated or are battling reliance on alcohol or drugs to get them through. An EAP gives employees someone to talk to and reach out to when they feel alone in a foreign land. It can also support their families and children who can develop mental health issues such as anxiety or depression when posted abroad and removed from their familiar situation. Global EAPs have expanded over the years to provide that vital support for the whole family, not just the employee.”
In certain countries, Dennis says, mental health conditions won’t be covered by private medical insurance because they aren’t recognised as illnesses. Providing a global EAP, therefore, ensures that employees and their families get access to related services.
Discretion is key
People employed overseas in high-income, high-pressure posts might understandably be reluctant – and embarrassed – to seek help for a mental health problem, fearing that it might not be career-enhancing. Can EAP providers and employers help overcome this?
“It’s about changing preconceptions in the minds of people who might benefit from these services, and thinking about how we position them,” said GGH’s Leatherby. “They are independent and completely confidential services, so they can be used without any fear of implications. Employers would certainly not be told about it, not at all. It’s away from the insurance policy; we don’t link it to that, and the data from the use of those services is kept completely separate, so there’s no possibility of people being identified. We’ve got an obligation, anyway, to protect our members’ data in accordance with GDPR regulations, so we wouldn’t be providing employers with any information in any event. As an extra protection, we’re saying it’s not even a part of the claims process; it’s just a free service to which people have access. We’re providing access to that service, but we’re not managing it. It can be done by video conferencing, telephone or online.”
Digital communication can certainly help overseas staff maintain discretion around accessing mental health services, says GeoBlue’s Madden. “Traditionally, mental health concerns meant scheduling an office visit with a psychiatrist or therapist, but the stigma with doing so in some cultures might prevent people who are in need of counselling from seeking care, and access to quality mental/behavioral care can be limited in certain parts of a given country.
“This can be even more challenging for expats who find themselves needing care in foreign and unfamiliar locations where language could pose another barrier. Remote access to a doctor or therapist for counselling support can help remove these obstacles to care. EAPs, in general, normally see low utilisation compared to the number of people who have mental health concerns but creating digital awareness campaigns can increase engagement. At GeoBlue, we want our members to be as aware as possible of the services their EAP offers. We regularly include information about our offerings in our member newsletters, and we have added access in our member mobile app to connect with EAP services. We have a wellness portal that provides content as well as access points to request counselling, a wellness coach or a work-life referral. Convenient access is also essential. Offering toll-free, 24/7 access telephonically or via video and through a mobile app can help drive engagement and usage.”
It’s prevention rather than cure. If you have a motivated, assimilated and healthy person who is confident in his or her environment, they’re going to be a productive and valuable employee
The tech game-changer
Aetna’s Dymoke explains how digital technology has been making an impact on healthcare services for some time. “As telemedicine and virtual support continue to improve, they are becoming easier to use and rising in popularity, making them a highly desirable benefit. When people are experiencing poor mental health, for example, they might have a preference for seeking face-to-face support or opening up via a voice call. Telemedicine is ideal as it offers both video and phone call options. It really enables us to meet people where they are, in relation to their circumstances, geography and health goals. It’s also important to provide a medical pathway alongside EAPs, partly because sometimes individuals want to speak to a doctor and partly because mental health conditions don’t always appear in isolation and can be a co-morbidity issue.
“Telemedicine provides a convenient entry point to that pathway as well as seamless care, especially when solutions such as EAP and vHealth are integrated so that professionals in both arenas can cross-refer members and patients to the right services for their needs.”
Towergate’s Dennis adds: “Globally, mobile people won’t necessarily have access to a traditional phone line, or they might be working in proximity; for example, on an oil rig, and want privacy to speak to a professional counsellor. Providing an online app makes it much easier for people abroad to speak to someone in their native tongue, within a few seconds, instead of having to navigate their way through a foreign phone system to get support. Technology is now the EAP providers’ priority for all their customers. After connecting via an app, the EAP can refer the person on for a Skype or video call to provide face-to-face contact if required.”
Support for all
There could be issues, suggests Leatherby, around the EAP benefits available to overseas staff based in parts of the world with good healthcare facilities compared with those in less developed regions: “There are questions of fairness and consistency. In a number of cases, there is a balance between providing the services employers feel their employees should have and the need corporations have to standardise as much as possible, which means some people will be covered more favourably than others. Someone posted in Europe is going to be able to take advantage of an advanced healthcare structure, while someone working in Africa might not be able to get access to the same quality of medical facilities. Here’s an example: Take someone working in Africa … If you have an EAP, it covers that person in the event of an emergency, but there are situations in which it might be best to take a non-urgent case out-of-country, so just having an EAP doesn’t necessarily meet the needs of the people who are in that country.
“Insurers such as ourselves have to find more innovative ways of being able to present benefits that apply to employees in specific situations. It is incumbent a little bit on us to come up with some solutions that aren’t leaving the employer to always be thinking about every situation.”
Working abroad can bring with it worries other than those that are health-related – mental or physical. Other stuff, too, can make life challenging.
It’s also important to relate it back to your employee engagement metric or score; has this gone up or down, and can it be linked back to the programme?
“It’s not just about health or counselling about how they’re feeling … there’s also financial counselling,” said Leatherby. “Even if you are going to a place such as Hong Kong, for example, housing and taxation is different; the ways you have to manage your finances are different. The counselling services we provide in our EAPs include those aspects. Financial worries can create anxiety and depression, too. It’s the whole situation that you have to think about.”
That’s a view supported by Dennis, who says that for a global business, EAPs focus not only on health and wellbeing, but also on a wide range of issues that could cause stress for employees. They have to offer legal advice, financial support and divorce advice. “It needs to be somewhere they can turn to for many issues,” she said.
Employers, she told ITIJ, also want their international EAP to offer cover for the spouse and children as well as the employee, recognising that support is needed for the whole family abroad, as anything affecting family members will have an impact on the employee: “Global EAPs now provide long-term support for the whole family rather than just a phone line for employees. They look to offer a service that can link people through to other services they might need and to refer to other professionals when required.”
Personalisation and connection
Aetna advocates ‘a seamless experience’ for employees through the use of integrated, connected solutions. “We know,” said Dymoke, “that plan sponsors are looking for aggregated data to understand how the solutions are being used, and ways to increase engagement to ensure better return on investment. Over and above their duty of care, employers are looking for propositions that curate technology with resources and guidance, so employees can personalise care according to their unique health profile and circumstances. For example, a good EAP proposition for a business with globally mobile employees would most likely include pre-, during- and post-assignment planning support, and feature remote access to holistic healthcare for the employee and their family too.
“The point around holistic health is really important. There’s an increasingly sophisticated understanding of the determinants or dimensions of health and wellbeing, including financial, social and character strengths, as well as the delicate, intertwined nature of our mental, emotional and physical wellbeing. With knock-on effects for performance, engagement and happiness – not to mention the bottom line, given that depression and anxiety cost the global economy somewhere in the region of US$1 trillion each year in lost productivity – organisations are increasingly looking to cater for any aspect that could have an impact. A comprehensive EAP service is perfectly placed to offer timely access to training, support and information, coaching employees through their challenges and helping them achieve better health and overall wellbeing.
“In the future, I think we’ll see a far greater emphasis on digital and engagement tools that focus on building communities. A good example is Hive, which enables users to create special focus groups that can develop communities for support conditions, wellness initiatives and so on. There is huge scope for building this type of functionality into EAPs and encouraging more peer-to-peer support.”
In the same way that sustainability and corporate social responsibility are now key business performance indicators, initiatives around emotional and mental wellbeing should be, too
Protecting the bottom line
EAPs cost money, so what are the benefits for employers? Is there a cost-benefit that shows up on the bottom line?
“It’s very difficult to put a money number on it,” said Leatherby. “It’s prevention rather than cure. If you have a motivated, assimilated and healthy person who is confident in their environment, they’re going to be a productive and valuable employee. You want people to be able to come into work every day giving 100 per cent and not having the anxieties and worries that prevent them being valuable employees. There isn’t really a straight cost-benefit, it’s more a case of what environment do you have that ensures they have a successful assignment?”
Dennis agrees that the EAP is a preventative service, giving employees and their families somewhere to turn to before problems escalate too far: “In that way, they can help to reduce levels of staff sickness absence. With people having somewhere to turn to online they don’t need time off for appointments, and support for mental health issues can help support people back into work more quickly. EAPs also work well in conjunction with PMI schemes, reducing the number of claims required and potentially helping to keep costs down.”
The answer, according to Dymoke, depends on what a company wants to solve in the first place. “Is it employee sentiment, retention, reduced absenteeism and decreased attrition? Perhaps an increased rate of assignment success or an increased uptake of benefits and therefore a better return on investment? Or is it simply more effective cost containment? For some of these, there are hard metrics that can be broken down into office, branch, country and programme levels. But to be valuable, these measures must link back to the organisation’s overarching objective. Whatever the objective, it’s certainly worth setting a benchmark to measure success against. Analysing population requirements and expectations, particularly against similar regional and global populations, can really help employers shape benefits provision and workplace policies. It’s also important to relate it back to your employee engagement metric or score; has this gone up or down, and can it be linked back to the programme?”
Once the problems an employer wants to solve have been identified, they need to apply realistic measurements that can be captured and reviewed regularly, she says. “There’s little point in doing lots of work to implement a strategy and then leaving it to its own devices for the next few years. It needs constant tending and tweaking to help ensure return on investment, as well as consistent top-down buy in from leadership. In the same way that sustainability and corporate social responsibility are now key business performance indicators, initiatives around emotional and mental wellbeing should be, too. We need to start thinking about performance scores related to culture and employee values rather than risk scores. This is the only way to develop an open, accepting culture in which it’s okay to talk about not feeling okay.” ■