Employee Engagement in the NHS: A Secondary Data Analysis of the NHS Healthy Workforce and Britain's Healthiest Workplace Surveys

by Marco Hafner, Martin Stepanek, Eleftheria Iakovidou, Christian Van Stolk

This Article

RAND Health Quarterly, 2020; 9(1):3


Staff health and wellbeing is an important area for employers. Leading a healthy life, both physically and mentally, helps the individual health of employees, but also benefits employers through boosting productivity in the workplace. The Five Year Forward View strategy, published by NHS England in 2014, underscores the importance of staff health and wellbeing as a crucial factor in improving the performance of the NHS and chief executive Simon Stevens announced a number of new initiatives and policy developments aimed at improving health and wellbeing within the workforce in 2015. RAND Europe conducted an independent study to examine the factors associated with engagement among NHS employees as part of a project with the Health Foundation, a charity committed to bringing about better health and healthcare in the UK. RAND Europe analysed data from the NHS Healthy Workforce Survey, conducted in 2016 across 35 UK NHS organisations, as well as VitalityHealth's Britain's Healthiest Workplace (BHW) survey in 2016, which involved RAND Europe's analysis of the survey results. The views expressed in the study are the authors' own and do not necessarily represent the views of the Health Foundation.

For more information, see RAND RR-2702-THF at https://www.rand.org/pubs/research_reports/RR2702.html

Full Text


This study aims to explore staff engagement in the English National Health Service (NHS), looking at the evidence on staff engagement, and how this may be linked to patient outcomes and organisational results. This study aims to make a contribution to the debate around the importance of improving employee engagement in the NHS. It examines some of the factors associated with employee engagement in the National Health Service (NHS) and further investigates whether there are associations between employee engagement and individual and organisational outcomes—such as rates of absenteeism or presenteeism—as well as a better quality of care and even better financial performance. This study represents the findings of the secondary analysis of the NHS Healthy Workforce and Britain's Healthiest Workplace surveys.

Research Approach

This study uses multivariate regression techniques to assess the associations between employee engagement and its determinants as well as specific outcomes, such as levels of absenteeism or presenteeism, staff turnover, patient satisfaction and financial performance. The analysis presented in this report aims to be complementary to previous seminal work on staff engagement in the NHS (West & Dawson, 2012) that used the NHS Staff survey as the backbone of its empirical analysis. The analysis in this study is based on data from the NHS Healthy Workforce survey in 2016, combined with information from the 2016 Britain's Healthiest Workplace survey and other additional NHS data sources. The NHS Healthy Workforce Survey was conducted by RAND and collected responses from employers and employees using two surveys: the Organisational health assessment (OHA) and the Employee health assessment (EHA) respectively. Participating organisations returned the OHA, including general organisational characteristics such as the size of the organisation, perspectives on work culture and the work environment and information on the organisation's approach to health promotion and well-being interventions. The EHA captures the general health of employees, the interventions that employers offer and wider information on the work environment and culture. The Britain's Healthiest Workplace (BHW) study was broadly identical (90 percent of the questions were identical) to the NHS Healthy Workforce survey, and collected data on additional NHS health organisations over a similar period. BHW also collects data on employers and their employees in other sectors across Great Britain.

Overall, data from 28 NHS organisations are included in the surveys (NHS Healthy Workforce Survey and BHW) and responses from over 9,000 employees are analysed in more detail. The added value of using this data is that it includes a large number of variables—including information on the personal background of respondents, their health and well-being and lifestyle behaviour—as well as information at the organisational level about health and well-being and leadership engagement.

While the data has its strengths, it is important to note that while the participating organisations represent a diverse range of NHS organisations, generalisations of the findings to the wider NHS should only be made with some caution. The sample of participating organisations in the NHS Healthy Workforce survey and BHW was not intended to be representative of the entire NHS, although we find that the findings most likely could apply to the wider NHS. For instance, the participating health organisations have been either selected by NHS England or have self-selected to participate in the survey. Hence, they may not be fully representative among the overall population of health organisations. In addition, there was a varying response rate within organisations (with an average response rate of 8 percent). Nevertheless, the distribution of employees in the survey is very similar to the distribution across different subgroups in the NHS staff survey, which gives some confidence that the survey is broadly representative for some of the specific employee groups. In addition, the statistical analysis adjusts for many factors that are potentially correlated with sampling bias, which mitigates to a large extent the issue of sampling bias in the findings presented in this study.


Comparing the NHS to other sectors in the UK, the findings suggest that employee engagement in the NHS is lower than in some UK sectors (e.g. media and telecommunications, professional services) but better than in others (e.g. financial services or logistics). Our findings suggest that staff engagement in the NHS in many ways is similar to other large employers with a similar demographic composition among their workforce. A summary of the most relevant factors positively or negatively affecting engagement is reported in Table 1.

Table 1. Summary of Factors (Positively and Negatively) Associated with Engagement

Variables Coefficient Lower Bound Upper Bound
Factors negatively associated with engagement
HSE: bullied in the workplace –0.0958 –0.109 –0.083
Elevated mental health risk –0.0749 –0.085 –0.065
HSE: peer support –0.0745 –0.092 –0.057
Life satisfaction (dissatisfied) –0.073 –0.083 –0.063
HSE: role is clear –0.0652 –0.08 –0.051
HSE: control –0.0581 –0.072 –0.044
HSE: strained relations –0.0549 –0.069 –0.041
Job: admin –0.036 –0.051 –0.021
Sleep quality (lack of) –0.033 –0.046 –0.02
HSE: unrealistic demands –0.0227 –0.035 –0.01
Job: general management –0.0166 –0.028 –0.005
Job: social care –0.0105 –0.017 –0.004
Factors positively associated with engagement
Number of health check interventions offered 0.0242 0.012 0.036
Home flexitime 0.0178 0.006 0.029
Number of physical health interventions offered 0.0155 0.001 0.03
Job: nursing and healthcare assistants 0.014 0.002 0.026
Number of leadership interventions offered 0.0093 0.001 0.023

SOURCE: Authors' calculations.

NOTES: HSE = Items from the UK Health & Safety Executive Management Standards Indicator tool, measured on a 5-point scale. Analysis based on NHS Healthy Workforce survey and BHW 2016 survey. Entries report standardised regression coefficients with mean 0 and standard deviation of 1. The coefficients represent the magnitude of the association between the variable and the engagement indicator used in the analysis.

The findings suggest that a number of demographic factors in our sample, including gender and age, are associated with levels of engagement (as measured by the engagement indicator used in this research). For instance female employees tend to report higher levels of engagement, whereas engagement decreases with age but plateaus in the mid-fifties, and then increases again (however, it does not reach the levels seen in early age until retirement age).

In addition, employees working in different NHS occupations report different levels of engagement. For instance, among employees in administration and general management in our sample, levels of engagement tend to be lower on average. In contrast, employees in medical and dental occupations, and nursing and healthcare assistants tend to report higher levels of engagement. This may be because frontline personnel may see their role more as a calling than support staff and managers. Organisational tenure seems to matter as well. Interestingly, engagement in our research tends to be highest in the first two years and then steadily declines until about 12 years of tenure. Then, engagement seems to rise again. This may suggest a selection effect, as those employees staying longest may be the most engaged, and most identify themselves with the organisation.

Furthermore, the work environment matters. The empirical findings suggest that employees who have flexible hours and can work from home once in a while report higher levels of engagement. This speaks to understanding the demand for flexible working among NHS staff and taking more proactive steps to accommodate some of these demands. This may help with managing home-life balance, dealing with working antisocial hours, and indeed managing other caring responsibilities. Also, employees who report high levels of workplace stress, a lack of control, and are not clear about their role, have lower levels of engagement. Employees who report being bullied or have a lack of peer support in the workplace tend to be less engaged on average. Finally, offering certain health and well-being interventions is also associated with higher levels of engagement. In particular, offering more interventions—especially in regard to general health (physical health), as well as those targeting senior leaders within the organisation—and making employees aware of them are associated with higher levels of engagement.

When looking at outcomes on the employee and organisational level in the NHS, the findings suggest that engagement is good from an individual and organisational point of view. Higher levels of engagement in our sample are associated with lower levels of presenteeism, as well as lower sickness absence rates. In addition, trusts with a relatively high level of engagement among their workforce tend to report a better financial situation and receive better ratings from patient-quality surveys. Hence, it seems that driving engagement higher makes business sense.


West, M., and J. Dawson, Employee Engagement and NHS Performance, The King's Fund, 2012.

The research described in this article was conducted by RAND Europe.

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