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Pay Might Exert Only 'Modest Impact' on NHS Staff Retention

Work-related stress, workload intensity, and staffing levels were primary drivers behind NHS staff deciding to leave their jobs, according to a study of survey results.

A research team, led by the University of Bath, said the findings suggested that pay increases alone might be insufficient to fix current staff retention problems. They noted that in the third quarter of 2022, NHS staff vacancies reached a 5-year high, with approximately 133,400 (9.7%) full-time equivalent posts unfilled. 

To gain an understanding of the key drivers behind decisions to quit the NHS, the researchers conducted a UK-wide online quantitative survey involving 1958 health professionals from acute, mental health, community, and ambulance services. The survey, which covered the summer and autumn of 2021, included 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.

Using a paired comparison technique, respondents were presented with randomly-ordered pairs for all permutations of eight 'push' factors – 28 selections each. For each pair, participants were asked: 'Which of these two factors is the bigger influence on why staff in your profession/job role leave the NHS?' 

The factors were: 

  • Time pressure 
  • Working hours 
  • Workload intensity 
  • Work–life balance
  • Pay 
  • Mental health/stress
  • Recognition of contribution
  • Staffing levels

Stress, Workload, and Staffing Levels Primary 'Factors' 

The results, published in BMJ Open, revealed that overall, staff 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. Most professional groups ranked pay fourth or fifth, although remuneration was considered more important by healthcare assistants and other nursing support staff, and by paramedics. 

The researchers said that while increases in pay were "transparently important", their findings suggested that enhancements in pay alone might produce only "a modest impact" on retention. The same might be true of "the current high-profile emphasis on increased access to flexible working hours". While both "have potential", neither may deliver sufficiently to redress the "high and rising exodus" without attention to "more fundamental factors driving exit", they suggested.

"Extremely Low Morale in NHS Ambulance Services"

Paramedics were "an outlier", the authors noted, exhibiting a profile "significantly different from other health professionals", giving work stress, work-life balance, work intensity, and pay higher relative weighting than the other professions. Work-life balance in particular emerged as a stronger driver, ranked second by paramedics, compared with fourth or fifth across other professions.

Asked to comment by Medscape News UK, Richard Webber of the College of Paramedics said: "The College continues to be concerned about the ability of NHS ambulance services to maintain adequate numbers of paramedics to provide the desired levels of service."

He noted that although university places on paramedic degree programmes were "heavily oversubscribed", retention of paramedics was a major workforce problem, "as evidenced by the numbers of paramedics now working in alternative healthcare environments". Pandemic experiences had led to many paramedics "re-evaluating their work life balance and reconsidering their working patterns".

Mr Webber added: "The College believes that in large part, poor retention is driven by extremely low morale." Factors affecting morale included pay falling behind inflation, increases in the number of hours staff were being asked to work, and more opportunities outside the ambulance service requiring less evening and weekend working.

Resolving NHS Workforce Issues "Not About Pay Alone" 

Also commenting to Medscape News UK, Professor Kamila Hawthorne, chair of the Royal College of General Practitioners agreed that the survey showed that workforce retention was "not about pay alone". Issues that have been "decades in the making" can't be resolved overnight, she said.

"Many GPs are experiencing huge workloads, resulting in burnout, low morale, and a sense of moral distress. We know that when GPs do leave the profession earlier than planned, it is often due to the pressures of the role, which have worsened in recent years. 

"In many instances, when a practice loses a member of staff, it is really difficult to find an equivalent replacement, intensifying the pressures on those remaining. College surveys have shown that this cycle is likely to get worse, with many of our fully qualified GPs considering leaving general practice in the next 5 years."

Professor Hawthorne highlighted that there are currently 952 fewer fully qualified, full-time GPs than in 2019, and the pressures "look set to continue for the foreseeable future", which would "continue to compound the workforce crisis we're facing".

The research was funded by the Economic and Social Research Council.

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