Pay increases alone may not be sufficient to fix NHS staff retention, researchers suggest

Work stress, high workload, and understaffing are the primary factors driving health professionals out of the NHS, suggest the results of a survey published in the open access journal BMJ Open.

The findings prompt the researchers to suggest that pay increases alone may not be sufficient to fix NHS staff retention.

There are well over 100,000 staff vacancies in the NHS. And worsening retention of NHS health professionals has been attributed to the fall-out from the COVID-19 pandemic. 

To explore this further, the researchers wanted to assess the relative importance of widely cited ‘push’ factors behind decisions to leave the NHS, and whether these were ranked differently by profession and NHS setting, a year after exposure to the effects of the pandemic.

During the Summer and Autumn of 2021, 1958 NHS health professionals from across the UK completed an online survey to determine the relative importance they gave to 8 factors as the key reasons for leaving NHS employment.

In all, 227 doctors; 687 nurses/midwives; 384 healthcare assistants and other nursing support staff; 417 allied health professionals, such as physiotherapists and occupational therapists; and 243 paramedics from acute, mental health, community, and ambulance services, completed the survey.

To produce reliable rankings, the survey used the paired comparison technique, whereby each respondent was presented with two push factors at a time, for all combinations of pairings, and asked to indicate: ‘Which of these two factors is the bigger influence on why staff in your profession/job role leave the NHS’?’

The factors compared were: staffing levels; working hours; mental health/stress; pay; time pressure; recognition of contribution; workload intensity; and work–life balance.

Overall, health professionals ranked work-related stress, workload intensity, and staffing levels as the primary ‘push factors’ underpinning decisions to leave the NHS. Recognition of effort and working hours were ranked lowest. But there were differences in the order of importance and relative weighting given to the push factors among the different health professions.

This was sharpest for paramedics who, relative to staffing, gave work stress, work-life balance, work intensity and pay higher relative weighting than the other professions. Paramedics also ranked work-life balance as a stronger driver to leave the NHS. They ranked this second compared to a fourth or fifth ranking across the other professions.

Pay was considered more important by healthcare assistants and other nursing support staff and paramedics, but was generally ranked fourth or fifth by other professional groups. 

This contrasts with “some contemporary media and industrial relations accounts, and some academic research findings,” say the researchers, who nevertheless add: “While other variables appear to exert a stronger push than pay, this is not grounds to diminish it as a potential source of dissatisfaction in absolute terms.” 

Work intensity in acute care hospitals and community services; time pressure in community services; and recognition of effort in mental health services were given higher relative weightings.

“In common with the NHS annual staff survey and all other voluntary participation employee surveys, the potential for self-selection response bias cannot be discounted,” emphasise the researchers. 

But they conclude: “Excepting paramedics, rankings of leave variables across the different health professional families exhibit a high degree of alignment, at the ordinal level, and highlight the primacy of psychological stress, staff shortages, and work intensity.”

They add: “While increases in pay are transparently important to NHS staff, findings from this research suggest that enhancements in that domain alone may produce a modest impact on retention.

“An equivalent conclusion might be drawn with respect to the current high-profile emphasis on increased access to flexible working hours as a solution within contemporary NHS staff retention guidance to employers. 

“Both have potential to do good, but there are grounds for inferring there is a risk that neither may deliver sufficient good to redress the high and rising exodus in the absence of attention to what present as more fundamental factors driving exit.” 


Notes for editors
Determining the relative salience of recognised push variables on health professional decisions to leave the UK National Health Service (NHS) using the method of paired comparisons doi: 10.1136/bmjopen-2022-070016
Journal: BMJ Open

Funding: Economic and Social Research Council

Link to Academy of Medical Sciences press release labelling system

Externally peer reviewed? Yes
Evidence type: Observational (survey responses)
Subjects: People