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Staffing issuesSep 11, 2023

Work stress, workloads and understaffing drive physios and other health professionals from the NHS

A combination of work stress, high workload, understaffing and other factors is driving health professionals from the NHS, according to an article published today (12 September) in the open access journal BMJ Open.

The researcher team, who reached its conclusions based on the results of a survey suggests that improving pay rates in isolation may remedy the NHS’s staff retention problems.

There more than 100,000 staff vacancies in the NHS, with worsening retention rates in the NHS often blamed on the aftermath of 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.

Photo Credit: Shutterstock
Pay increases alone may not be enough to improve staff retention, the research suggests


During the summer and autumn of 2021, 1,958 NHS health professionals from across the country completed online surveys on the relative importance they would give to eight 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; 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.

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 [Tomas Ferreira et al]

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. 

Fundamental factors

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,’ the researchers state. 

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.'

The article is titled 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

Author: Ian A McMillan
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