The hidden work in health care: unpaid overtime in the NHS (The Health Foundation, 15 August 2025)

Summary

The NHS relies on a workforce of around 1.5 million people to deliver care in England. The NHS annual staff survey shows that for at least the past 20 years, half or more of these people have worked additional unpaid overtime, above and beyond their contracted hours – often referred to as ‘discretionary effort’. This has consistently allowed the health service to treat more patients and offer better quality care.

The COVID-19 pandemic appears to have been a watershed moment for unpaid overtime in the NHS (as it was for many other areas). The Darzi review noted a ‘marked reduction in discretionary effort across all staff groups’, after the stress and exhaustion that NHS workers had endured throughout the pandemic. An NHS England public board paper (from May 2024) also considered how this reduction in overtime might be affecting overall NHS productivity. And the 10 Year Health Plan also highlights a dip in intrinsic motivation as evidenced by falls in discretionary effort. 

But understanding the changes in NHS staff unpaid overtime is complex. Whether people work extra hours depends not only on their willingness or motivation to do so, but also on the demand for their time – driven by patient needs and gaps in staffing. The publicly available data do not allow us to fully assess the relative contribution of each, the interaction between the two, or the impact that working unpaid hours can have on staff themselves.