Introduction

NHS staff are both its greatest asset and its greatest cost. There have been longstanding concerns about whether the NHS has sufficient staff in the right roles, now and in the future. These concerns have been exacerbated by the impact of the Covid-19 pandemic which has negatively affected staff wellbeing and productivity, as well as a series of pay disputes which may have lasting impacts on relationships between staff and NHS employers.

Key issues facing the NHS are ensuring that sufficient numbers of staff want to stay in their current roles while working sufficient hours, as well as ensuring there is a pipeline of new recruits to meet changes in skills and loss of staff from retirement or other reasons. As our previous research has shown, this is not just a question of considering the numbers of joiners and leavers, although these are important, but also changes in career choices and paths. There are already indications that people coming into the workforce more recently may not make the same career choices as previous generations. For example, we know that:

• There has been a dramatic fall in nursing graduates joining the NHS after training: 6,325 fewer new nurses with a UK nationality joined NHS hospital and community services in the year to March 2022 compared with the same period two years before that (a fall of 32%).
• Fewer doctors move directly from training to a specialism: in 2012 two-thirds (66%) of doctors completing foundation training entered specialty training in the NHS within a year, whereas a decade later the proportion had fallen to a quarter (25%).
• More GPs are working part-time: for example, in the year to September 2024, GP joiners ¹  were contracted to work 3.5 hours less on average than the joiners eight years prior.

But it’s not just the younger generations who may be making different decisions – for example, the proportion of GPs claiming a pension on a voluntary early retirement basis was twice as high in 2022 (40%) than in 2008 (20%).

Understanding what drives and motivates health care workers – both those already in the job and those who want to join – could help the NHS in efforts to create fairer policies for pay, working conditions and career opportunities. 

Of course NHS staff are impacted by wider changes in society, workplace norms, and employment opportunities in other sectors. The pandemic accelerated changes in working patterns, with an increase in home working, for example, facilitated in the NHS by more health care now being delivered remotely. In the wider economy, the changing expectations of work of younger generations have been highlighted, while lower labour force participation of older workers has also caused concern. These wider trends will also have an impact on the expectations of people in the NHS workforce and could lead to unanticipated changes in motivations of NHS staff.

In this briefing we report on novel analysis of over 1 million responses from the NHS staff survey. Our analysis examines how the experience and motivations of staff differ between age groups, and whether there is evidence that the role of age on experience has changed over time. This survey – understood to be the largest workforce survey in the world – has been conducted annually since 2003 and so provides an opportunity to examine change over the last 20 years. Understanding the impact of age, and if and how this is changing, can support NHS employers and policy-makers in developing and implementing solutions to ensure a sustainable workforce.

In our analysis we examine responses from professionally qualified clinicians at various points between 2003 and 2023 and consider three different types of change which might be taking place:

• Generational effects (also called cohort effects) – where experiences of a given age group are different now to those of earlier generations.
• Period effects – where there are underlying shifts in the social context or environment which affect all age groups at the same time.
• Age effects – where changes occur as people advance through their careers. This is often related to different life stages (for example, starting a family).

Is there evidence that experience and motivation differ between staff from different generations?

Generational effects, also known as cohort effects, are differences in attitudes and behaviour between generations which arise and then remain regardless of age or period. These often occur when a generation experiences an event during their formative years that continues to shape their attitudes and behaviour. For example, millennials graduated during the 2008 global recession which influenced their early career, and for Gen-Z, the Covid-19 pandemic will have a long-lasting impact.

The oldest age group has become more different from other groups

Evidence from the NHS staff survey shows that responses from the oldest age group tend to become more divergent from their colleagues on issues that did not otherwise vary by age.

Before 2009, the proportion of respondents who said they “agree” or “strongly agree” that they achieve a good balance between work and home life was similar across age groups. However, in recent surveys those aged 66+ have been substantially more likely to agree or strongly agree with this statement.

A key factor in the older age group dispersing may be the nature of this workforce, the majority of whom will have reached the age to receive their state pension and will have been able to receive their NHS pension for some years. NHS staff who continue to work beyond pensionable age may have different motivations from those who retired, although it is less clear why this has changed over time. Those aged 65 and over now make up a greater proportion of full-time workers than they did 10 years ago. Older survey respondents in more recent surveys are also more likely to be men than in the earlier years and other age groups (see table in the Appendix), which could also contribute towards changes in attitudes of this generation of older workers.

We observed a similar pattern when looking at resources and staffing. The percentage of respondents who “strongly agree” that they have adequate resource to do their jobs increased at a faster pace amongst those aged 66 or older than other age groups, who instead have seen a far more gradual increase between 2009 and 2023.

Similarly, the percentage of respondents who “strongly agree” that there are enough staff at their organisation to do their job properly has increased over time from 2009 to 2023. However, from 2013, the attitudes of those aged 66 or older has diverged from those of other ages.

There are some instances where the youngest age group have become more different from other age groups

Surprisingly, we only identified two instances where the youngest age group have become more different from older age groups, counter to the popular narrative that younger workers have diverging attitudes to work. One clear example came from the hours of additional paid work undertaken by younger NHS staff. From 2013 onwards, the proportion of workers aged 30 and under doing six or more, or 11 or more hours of additional work grew at a much higher rate than was the case in other age groups, as shown in the charts below. This may reflect rising financial pressures faced by younger NHS staff, potentially driven by factors like increasing housing costs and wage stagnation.

Are some changes in people’s experiences evident across all age groups?

Period effects are changes in NHS workers’ attitudes and behaviours that arise from events that impact everyone at the same time, regardless of age. Examples of these kinds of historical events or social changes include economic recessions, the Covid-19 pandemic, and the cost-of-living crisis. While these kinds of events will likely impact everyone’s views across a range of questions, we identified several aspects of experience that appear to be explained primarily by period effects, and highlight two here.

The first shows falling levels of patient contact amongst all age groups. The percentage of respondents with frequent patient contact fell by over 5% in all age groups after 2019, to just over 80% for the oldest age group and just under 90% for the youngest age group. This coincided with the start of the Covid-19 pandemic which resulted in a number of changes in the workforce, as well as changes in patterns of delivering care with more care delivered remotely to reduce infection risk.

The second example is opportunities to show initiative at work: the percentage of respondents who “strongly agree” that there are frequent opportunities to show initiative in their role has seen a sustained increase over time amongst all age groups. This welcome shift predates an aspiration included in the 2020 NHS people plan to promote staff autonomy.

How does experience vary between age groups?

Age effects – sometimes referred to as life-cycle effects – are changes that arise from growing older, regardless of generational change or historical events. These may reflect changes in NHS workers’ experience, health, risk aversion, family and relationships as they age. While age will likely play into many different aspects of the NHS staff survey, this section looks at questions where answers are primarily determined by age.

Perhaps unsurprisingly, older NHS workers are more likely to have worked more than six years in their role. Perhaps less predictable is the age effect we see in the percentage of respondents who say that time “always” passes quickly when working. This measure of job satisfaction increases steadily with age.

We then looked at questions on unpaid work. The percentage of respondents working six or more hours per week unpaid demonstrates a less straightforward relationship with age. In the chart below, we see that it is people aged 41-65 who do the most unpaid work, in contrast to those aged 21-30. However, there is no evidence that younger workers are becoming more averse to working longer hours without pay – this measure has not declined since 2009.

Is age becoming a more important factor in staff experience and motivation?

Our analysis identified a new pattern amongst NHS staff, one of rapidly emerging age effects where there was none previously.

Looking at pay satisfaction, in 2013 there was no difference in satisfaction between age groups. By 2022, there was almost a 25 percentage point difference by age, with younger workers being much less satisfied than older workers.

The two charts below show different aspects of job satisfaction and they follow a remarkably similar pattern. Both charts show that after 2019, the percentage of respondents who “never” or “rarely” looked forward to work, or felt enthusiastic about their jobs, became rapidly more different between age groups. While the youngest age group expressed similar attitudes to the oldest age group in 2013, by 2022 the percentage of unsatisfied young NHS workers was over triple that of the oldest age group.

It is difficult to pin-point exactly when this age stratification began, but it is apparent by 2022 and 2023 that younger people are less satisfied with their pay and work. While these changes could reflect increased financial pressures, as with changing work patterns, this has quickly impacted work satisfaction levels, too.

A critical question for the NHS is how differences in experiences impact on staff well-being.  The chart below highlights that a high proportion of NHS staff – even in the oldest age group – have felt unwell at work in the last 12 months as a result of work-related stress. It is also notable that the proportion of staff experiencing stress in the youngest age group has increased more than other ages, with over half of 21-30 year olds in the 2023 survey saying that they have felt unwell in the last 12 months.

Discussion

There are many aspects of staff experience where there has been greater divergence between age groups over time, particularly in relation to satisfaction with work and pay, undertaking additional paid hours, and work related stress. There are areas which showed little variation by age in early surveys but marked differences in the latest surveys. Many of these shifts in experience and attitudes have emerged recently, and it is difficult to assess over a shorter period whether the experience NHS staff have is going to continue to vary by age, or whether these effects are specific to some generations of the workforce.

Older age groups are generally more satisfied at work, while those aged between 41 and 65 are more likely to undertake more unpaid hours of work. The combined impact of public sector pay restraint and higher cost of living may explain the fact that staff in younger age groups are more likely than other age groups to work longer paid hours and are least satisfied with pay. Younger staff are also less satisfied with other aspects of work, and more likely to experience work-related stress. Younger workers have always been less likely to undertake unpaid extra hours than older workers, and this pattern hasn’t changed over time.

Our analysis of generational change is in line with some previous research. While generational shifts in the US health care workforce, particularly those focusing on millennials, have been studied extensively, the research findings have been mixed. There is evidence to suggest that younger generations of health care workers experience greater psychological difficulty and emotional exhaustion, while experiencing poorer well-being and work satisfaction. However, several articles from the US context found, for example, no significant differences in intention to leave between generations.

While the analysis for this paper focused on those already employed in the NHS, changes in behaviours are also evident from prospective staff as well as those already in or joining the NHS. For example, our analysis of a survey commissioned by Universities UK found that almost three in four young people are considering or have considered a career in health care (73%), with respondents saying that improving the lives of others (46%) and having a rewarding career (40%) are the most important factors for pursuing a health care career. But many of these same people are being put off from applying to study for health care qualifications by perceptions of low pay, lack of flexibility or work-life balance, and pressure or stress. While the number of English students applying to nursing has fallen, given the broad interest in NHS roles there are still opportunities to develop the pipeline of new staff.

Perhaps surprisingly, there has not been previous research using the NHS staff survey to examine differences between age groups and generations. There are a number of findings in this initial analysis which could be examined in more detail, for example for different clinical roles, and also considering other characteristics of staff, including gender, ethnicity and country of training. This further analysis might be helpful in unpicking the drivers and implications for the patterns we have found. We were limited to an extent by changes in questions used and wording over time.

Looking ahead, the differences between age groups, and divergence in staff experience by age, highlight the importance of taking account of the age composition of the NHS workforce when considering how to motivate and retain staff. As we have previously reported, the proportion of staff who are new in post has increased over time, resulting in fewer years of experience at work. The relative proportion of both 25-34 year olds and 55-64 year olds have simultaneously increased in the NHS workforce over the past 15 years (see appendix), which complicates how age effects could affect the workforce.

The growing diversity of experience in the workforce brings challenges for the NHS, along with mounting evidence, as discussed earlier, that NHS careers are becoming less uniform. Fewer people are moving straight from training onto specialisms and full-time work that continues until retirement age. This diversity indicates that at national level, and as individual employers, policy-makers and leaders need to examine more closely the age composition of staff groups and consider how to support and motivate staff at different stages of their career. For example, given that as a society our working lives are getting longer, and older workers show greater job satisfaction, the NHS should consider opportunities to retain staff in work for longer.

The high proportion of staff experiencing stress at work should remain high on policy-maker and employer agendas: quite apart from the NHS’s obligation to employees, there is long standing evidence of the link between better staff well-being and better safety, quality and performance of services. The greater impact of this on younger staff requires urgent investigation, both to ensure those staff are supported, and to prevent concerns over stress becoming a barrier to engaging the workforce of the future.