Five things we learnt from our work on the health and wellbeing of lower paid NHS staff

26 August 2021

About 3 mins to read

COVID-19 exposed and increased unjust and avoidable inequalities in our society. It also shone a light on the stark realities facing our health care workers. So now more than ever, as the largest employer in the UK, the NHS has both a significant opportunity and a responsibility to improve the health and wellbeing of its workforce.  

In 2020, we set out to learn more about how the NHS can improve the health and wellbeing of its lowest paid staff – those earning less than £24,157 a year (Agenda for change Band 4 or below). This work began before the pandemic and looked at pre-existing and long-term health and wellbeing, as well as exploring specific experiences during COVID-19. We’ll be publishing the full findings of this research later this year, but here’s a preview of some of the things we’ve learnt so far. 

1. Lower paid staff make up close to half of the overall NHS workforce 

Lower paid workers comprise 45% of the NHS workforce, with women making up 85% of this group. The jobs fulfilled by lower paid staff include clinical support roles such as health care assistants, and non-clinical support roles such as cleaners, porters, facilities, security and administration. Some of these workers are employed directly by the NHS, while others are employed through subsidiaries or private companies.  

The views of lower paid staff are often underrepresented. For example, the annual NHS staff survey attracted a 47% response rate, but of these only 3.2% of respondents were maintenance and ancillary staff. Many of the NHS workers who are part of this ‘hidden workforce’ of support roles are involved in direct patient contact, form a crucial part of a patient’s experience of the NHS, and are an essential building block as the health service recovers from COVID-19.  

2. Poor health and wellbeing is more common among lower paid NHS workers 

Issues regarding the health and wellbeing of NHS staff are increasingly well-documented. The 2019 NHS Staff Survey, reported that 40% of employees have felt unwell from work-related stress in the past year, compared to 1.8% of the entire UK workforce. These higher rates of ill-health amongst NHS staff cost the NHS £2.4bn per year and can negatively impact quality of care and patient outcomes.  

Our research examined the health and wellbeing of lower paid workers in particular, to complement work with other staff groups. We heard that lower paid NHS staff have higher rates of workplace stress, sickness absence and are at increased risk of long-term conditions such as diabetes and heart disease. They are also more likely to retire early due to ill-health.  

3. Lower paid staff face specific challenges around pay, career progression and feeling valued 

While some of the factors that affect the health and wellbeing of lower paid staff are applicable to other NHS staff, such as the impact of shift work and high workload, there are other factors that are specific to this group. They are more likely to be affected by socioeconomic conditions which can lead to poorer health and wellbeing, such as poverty and job insecurity. Some may face stressors created by working in more than one job.  

Many lower paid NHS workers report a lack of opportunity to progress to better paid roles and say that they feel undervalued and unsupported at work, with a sense of feeling ‘invisible’ unless something goes wrong. And while having a sense of autonomy at work is closely linked to job satisfaction, lower paid workers often feel they have no autonomy at all. The 2019 NHS Staff Survey reported that 52% of the overall workforce felt involved in making decisions related to their area, team or department, but only 39% of maintenance/ancillary staff and 41% of health care assistants felt the same way.

Other factors affecting the health and wellbeing of lower paid staff include increased exposure to racial discrimination, being involved in physically demanding work or working with potentially hazardous materials such as in cleaning, laundry and catering roles. 

4. Understanding the barriers and enablers associated with good health and wellbeing will help to drive positive change within NHS organisations 

Good health and wellbeing are important for the ‘health’ of the system. While many organisations have positively responded to the pandemic with an increased focus on staff health and wellbeing overall, initiatives have infrequently focused on the lowest paid staff. Lower paid NHS workers’ experiences of organisational health and wellbeing programmes point to a range of factors. 

They are less likely to access workplace health and wellbeing interventions. Issues include the relevance of schemes to staff in lower paid roles, and the potentially unequal access NHS staff can have to them, including for those employed through outsourced contracts. Careful consideration needs to be given to the logistics of interventions, such as scheduling, location and mode of delivery to better engage this group. Organisations with higher levels of staff engagement, have lower rates of sickness absence, improved patient experience and higher levels of staff retention. 

5. There is plenty that organisations can do to support better health and wellbeing in lower paid staff  

Lower paid staff often highlighted the disconnect between the initiatives they wanted to see, versus what their employer thought was needed and delivered. Creating opportunities for lower paid staff to co-design programmes and ensuring manager support for involvement were found to be crucial enablers of participation. 

Clear communication channels, strong representation and a voice within the organisation were all highlighted as important to wellbeing at work. Financial incentives and support that promote physical health and wellbeing, such as discounts on gym membership were also cited positively. 

Beyond this, addressing the structural and social issues that impact the health and wellbeing of lower paid staff are important precursors to improving people’s broader health and wellbeing. This includes looking at the impact of pay, career progression and job autonomy, as well as cultural issues around value, respect and support. 

Find out more 

Watch out for the publication of our working paper on the health and wellbeing of lower paid NHS staff later this year which explores these and other issues in more detail.  


This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.

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