Good Management Saves Lives

The Whitehall Studies and The Social Gradient of Health

The relationship between seniority/status and psychological safety is strong. In general, we know that people holding more senior and higher status roles often feel safer speaking up in groups, and those in “low status” roles tend to self-censor more. But can a person’s seniority and status at work affect other things, such as their health, or risk of heart attacks?

Yes, it does, but not in the way we might think.

Typically, we might believe that individuals in higher status roles are more likely to suffer from stress-related illnesses, due to the higher pressure and responsibilities of their senior positions. Conditions such as high blood pressure and cardiovascular disease were often assumed to be more common amongst top executives, who faced the burden of making big decisions and carrying heavy responsibilities.

The Whitehall Studies

However, the findings from the now near-famous (at least in public health realms) “Whitehall Studies” reveal a different truth. These studies focused on the social determinants of health (SDH) among British civil servants, particularly looking at the prevalence and mortality from cardiovascular disease.

The first of these studies, Whitehall I, started in 1967 by Professor Sir Michael Marmot and colleagues, spanned ten years. Contradicting common beliefs, it found that men in the lowest employment grades were significantly more likely to suffer premature death compared to those in higher status roles. Whitehall II, the follow-up study that started in 1985 and still ongoing, was expanded to include women and further explored this “social gradient” in health within the workplace.

This “social gradient” refers to a pattern where individuals with lower socioeconomic status (including income, education, and occupational status) have poorer health outcomes than those in more advantaged positions, with greater disparities leading to more pronounced health inequities. In Whitehall I, it was observed that mortality rates were three times higher for men in the lowest employment grades compared to those in the highest, with health improving consistently alongside employment rank, a phenomenon Michael Marmot termed “Status Syndrome”. See the image below for the social gradient effect in respect to neighbourhood deprivation.

The Social Gradient in Health

Life expectancy and disability-free life expectancy (DFLE) at birth: England 1999–2003. Source: The Marmot Review (ONS).

The Whitehall studies were designed to control for the influence of variables other than job role status, and focused on a closely related set of occupations, where individuals in each grade were socially similar and lived in similar environments.

Further analysis of data from these studies showed that higher job stress, characterised by factors such as lack of skill utilisation, workplace tension, and unclear tasks, was linked to high blood pressure and cardiovascular disease. A subsequent examination of cortisol levels in the Whitehall II cohort revealed no significant difference in cortisol (a stress hormone, which is linked to heart disease) levels upon waking between different seniority levels. However, those in lower positions exhibited notably higher cortisol levels 30 minutes after waking, particularly on workdays. This was interpreted as a sign of chronic stress, especially due to the anticipation of stress later in the day.

Age adjusted mortality rate ratios in a 25 year follow up of civil servants from the first Whitehall study. Rossum et al, 2000. (Note: “Administrative” is the highest status role in this context.)

The figure above illustrates a key finding made after the Whitehall Studies: lower status workers not only experienced poorer health during the study but also continued to face higher mortality rates from various causes of death as they aged. And this social gradient in health, where individuals with lower status at work have worse health outcomes, is not exclusive to the British Civil Service. Similar patterns have been observed in diverse settings, including among industrial workers in Finland, in national surveys in Sweden and the US, at Hawthorne Works, and within large organisations in Belgium. 

This indicates that the relationship between work status and health is a widespread phenomenon. Factors such as the way work is organised, work environment and cultural climate, as well as social influences, early life and health behaviours all contribute to the social gradient in health. 

From Sheffield Equality Group. People with intermediate or low job control (autonomy) had over twice the incidence of coronary heart disease. Data from Whitehall II study.

Job Autonomy and Health

What really stands out is that the authority to make decisions at work seems to be a crucial factor affecting stress levels. We might think of this as counterintuitive – surely those in higher status roles suffer greater stress through having to make “big” decisions, right? However, it turns out that those lower in the command hierarchy, with less control over their work and life, face greater stress. This lack of control is a major risk factor for cardiovascular disease. Having autonomy in how we work, including when and how tasks are performed, is associated with lower levels of cortisol, heart rate, and blood pressure compared to being micromanaged. Micromanagement is not only bad for team performance; it can kill people.

The upside of this is surely that the converse must also be true; good management saves lives. 

Social Determinants of Health

The social gradient in health demonstrates the key reason why we need to address societal imbalances in power, money and resources, and this research shows us that we can start in the workplace. If you’re interested in the social gradient in health, social determinants and why people at relative social disadvantage suffer health disadvantage and shorter lives, check out Professor Sir Michael Marmot’s “The Health Gap: The Challenge of an Unequal World”.  If you’d like to dive a bit deeper into the Whitehall studies specifically, I can recommend this excellent write up from the Sheffield Equality Group. I’ve also added some links to related papers and content below.

Note: The Whitehall II team have a data sharing policy, allowing researchers from other institutions to analyse raw data from the Whitehall II cohort. Read the policy and find out more here.

Further reading and links to papers:

Whitehall I: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1060958/pdf/jepicomh200004-0017.pdf 

Whitehall II: https://psychsafety.com/wp-content/uploads/2023/11/whitehall-II.pdf

Social Determinants of Health: https://www.who.int/health-topics/social-determinants-of-health/

The Glasgow Effect: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4979043/ 

Men make their own history, but they do not make it as they please; they do not make it under self-selected circumstances, but under circumstances existing already, given and transmitted from the past. 

The Eighteenth Brumaire of Louis Bonaparte. Karl Marx, 1852

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Psychological Safety at Work

Last week, I attended the Learning From Excellence conference in Birmingham, UK, which was centred on the theme of “hope”. It was a fantastic event, I had a wonderful time, got to meet a bunch of lovely people, and I’d like to congratulate the LFE organisers for doing such as awesome job. The LFE stance is that safety in healthcare has traditionally focused on avoiding harm by primarily learning from error, which may miss opportunities to learn from excellent practice.

Excellence in healthcare is found everywhere, but there is no formal system to capture it, and our preoccupation with avoiding error and harm in healthcare has resulted in the rise of rules and rigidity (something we often describe as an over emphasis on “Safety-I” approaches, whilst LFE leans towards Safety-II). The LFE approach is that by studying excellence in healthcare we can create new opportunities for learning and improving resilience and staff morale. LFE provide a mechanism for “Open reporting” of excellence in practice, where you can provide written positive feedback to a colleague, and what can be learned from that example of excellence. 

While at the conference, I came across Justin Aunger and colleagues’ research on drivers of and solutions to unprofessional behaviour between healthcare staff. You can see the poster below (click for high res), or dive into the more complete guide here. And here is the paper preprint: Drivers of unprofessional behaviour between staff in acute care hospitals: A realist review. Just to spotlight some of the findings, drivers of unprofessional behaviour include: workplace disempowerment, harmful processes and cultures, inhibited social cohesion, poor manager awareness, and a reduced ability to speak up. 

Here’s a great piece in Times Higher Education by Rob Kadel, about facilitating cross-team collaboration in research environments. Rob makes some excellent points about the oft-siloed nature of academia, and why multi-disciplinary research can present challenges in team formation and management. One challenge, for example, is simply in communication and nomenclature: terms familiar to folks in one field may mean something completely different in another, or be alien to them. What Rob is describing here (though he doesn’t use the term) is the creation of Team Charters – something we espouse a lot in our workshops, and work with many teams in their creation and maintenance. Drop Jade Garratt (jade@psychsafety.com) if you’re interested in exploring academic culture and topics such as this. 

One fantastic way to help spread and share the awareness, skills, and practices of psychological safety in an organisation is to create and grow a Community of Practice (CoP). Here’s a great resource from Emily Webber, including articles, tools and training on growing your own CoP!

This week’s poem:

The way to create art is to burn and destroy
ordinary concepts and to substitute them
with new truths that run down
from the top of the head
and out of the heart.

― Charles Bukowski

Tom Geraghty