Intended for healthcare professionals

Feature Round Table

How can the NHS become a millennial friendly employer?

BMJ 2018; 360 doi: (Published 09 March 2018) Cite this as: BMJ 2018;360:k1095
  1. Gareth Iacobucci, news reporter, The BMJ
  1. giacobucci{at}

With the NHS facing serious recruitment and retention problems, The BMJ hosted a round table at the Nuffield health policy summit asking how the NHS can do more to attract, enthuse, and hold onto young doctors. Gareth Iacobucci reports

The panel

  • Fiona Godlee, editor in chief, The BMJ (chair)

  • Candace Imison, director of policy, Nuffield Trust

  • Bob Klaber, consultant paediatrician and associate medical director, Imperial College Healthcare NHS Trust

  • Claire Lemer, consultant in general paediatrics and service transformation, Guys and St Thomas’ NHS Foundation Trust

  • Nishma Manek, GP trainee in London, national medical director’s clinical fellow

  • Clifford Mann, consultant in emergency medicine, Taunton and Somerset NHS Foundation Trust, and national clinical adviser for NHS England’s accident and emergency improvement plan

What are the main reasons for low morale and low retention?

Nishma Manek (NM): Most junior doctors don’t feel particularly valued in their jobs. The NHS doesn’t do the “H” in “HR” very well. I don’t think it necessarily comes down to immense [financial] cost, it comes down to behaviours. You’ve sort of lost the “firm” structure, but that doesn’t mean you can’t still create that feeling if you try hard enough.

Claire Lemer (CL): It’s all about creating that sense of team because that’s crucial to managing adversity. One of the crucial things is having really honest open conversations with trainees about what the job as a consultant actually involves: showing people, getting them to shadow you, spending time with you, but also listening to them, finding out what they do outside of medicine and what their hopes and aspirations are.

Clifford Mann (CM): One of the key problems is the mismatch between the workload and the resource to attend to that workload. In the places where the mismatches are greatest fatigue, burnout, and a sense of hopelessness set in.

Bob Klaber (BK): I think, being really brutal, we fundamentally fail to pay enough attention to people. We get stuck behind the structural and technical problems that sit behind it. So [for example], the working time directive has all sorts of serious and important implications for this, but it sort of gets the wholesale blame, and people shrug their shoulders and say, “I can’t do anything about that.”

Candace Imison (CI): We haven’t expanded the workforce at the rate that the work has expanded and the work has also got more complex and difficult. Burnout is a really significant issue for young doctors, and a lot of it has to do with being presented with situations you find very difficult.

CM: I think that the obsession with process confines the inner spirit, if you like, of the trainee. They’re not allowed to be imaginative, be creative, or think outside the box. We need to replace a lot of the processes with an understanding that if you get the culture right, outcomes will follow.

How can the NHS attract and retain millennials, who don’t necessarily want to work with one employer for their whole life and want more work-life balance?

NM: The way that we [millennials] have grown up has been shaped significantly by technology. Because in all the other aspects of our lives we can customise everything and get everything instantly, that sense of expectation is creeping into our work life, not unreasonably. I haven’t seen that the current system has got a plan to keep up with these expectations. Rather than blaming us, the NHS has got to learn to adapt to a generation that has a different set of cultural norms.

CI: I don’t think we have had nearly enough curiosity about what our workforce wants and needs and how we can support it in that. In the NHS people do put in a vast amount of discretionary effort, and employers have been able to be lazy employers because they had a lot of intrinsic motivation in the workforce. I think we’re challenging that at the minute. We need to think a lot more deeply about the training process. The professional bodies have a role in helping people understand how to be good trainers.

CM: As a flipside of that… we need to be honest when we invite people to apply to medical school that there is a core amount of work that has to be done. It’s fine to have a work-life balance, but if for you a work-life balance is only working in the day and never working in the evening or weekend, you may have chosen the wrong profession. I don’t believe that most millennials have ever thought anything other than it would be hard work, and that they would step up to the plate and do their fair share of it. But we mustn’t lose sight of the fact that acute healthcare is a fundamentally different job, and a fundamentally different work-life balance, from industry, law, teaching, and many other professions.

What can consultants do to support millennials?

BK: I think we [consultants] are incredibly skilled at listening to somebody, taking a history from them, making a diagnosis around thinking about their whole life. That’s not a wholly different skill that’s needed from thinking about other colleagues. The difficult bit is when you’re feeling tired and a bit “done to” by the system, you stop paying attention to that. As consultants, as GPs, as senior nurses, a core part of our role is to be an enabler for others.

CM: There’s going to be a new consultant contract sometime. Why don’t we give the profession the signals within the contract that people are taking the issues seriously? In Australia, New Zealand, Canada, and even Wales [they] afford people the opportunity to have a sabbatical or long service leave. It re-energises the individual, re-energises your department, it is what high performing companies do for their senior staff all the time. So why don’t we do it? The second thing is ... the work-life balance is appalling. Why don’t we link the amount of annual leave pro rata to the number of evenings, nights, and weekends people work? This would be extremely attractive.

CL: I think each of the clinicians around this table does work outside of their clinical work, whether it’s college work, advisory work, or a medical management role. It is much easier to give to the NHS if you’re also doing other things that empower you. We need to allow others to have that same flexibility, because it is a way to sustain you through what is proving to be a longer and longer career.

What would you say to Simon Stevens? How could he make a difference?

CI: He needs to model the behaviours that he wants to see in the organisation, and crucially, make sure that the people who work for him model those behaviours. At the minute, the system is sending the message you’ve got to deliver the bottom line, waiting list targets and four hour targets. It isn’t sending [the message] that you’ve got to care for our people as your number one thing.

CM: The thing I would say is ... his job is to fight the corner for the NHS, and to ensure it’s properly funded so that we can actually recruit people into properly funded posts, in environments that are sufficiently well equipped to make their job doable.

BK: It’s around tone and behaviour from the top. It’s nowhere near good enough. It has a massive effect cascading down ... and there’s a complete blind spot. I agree with Cliff [CM] to an extent, but straight away the word [he uses] is the “fight,” the sort of fist pumping fighter. This is a people endeavour.

And, for a young person joining the NHS, what would you suggest that they do to make sure that they thrive?

CM: We need to tell them that in exchange for, on occasion, working very hard and long hours, we will promote portfolio careers that allow you to undertake other aspects away from the frontline ... to recharge your batteries.

BK: Make connections and relationships. Some of those are going to be peer based, looking after each other, being generous to each other, being supportive of each other, and also finding mentors and supporters. I feel strongly that you can’t have enough informal conversations with people, mentoring conversations with people.

CL: If I was talking to a junior doctor, [I would emphasise] how much the little things matter and how much they can bring to the patients but also to themselves.

NM: It might feel like doors are being shut in your face, but you’ll find one opens if you push hard enough. Once you do that, that feeling of learnt helplessness often disappears and you suddenly realise you can make things better, even in your 20s and 30s. The second thing is, if you feel like we’re losing the firm structure do something about it yourself. Encourage your colleagues to go out for a drink on a Friday night after work, get your consultants out, have lunch with them. It doesn’t all come down to how other people should behave towards you.


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.