This is why doctors and nurses are leaving the NHS (money isn’t the top reason)

The man had been waiting two hours to be seen. Michael Buttrick ?just happened to be the nurse assigned to the next patient. When Buttrick went to bring him in, apologising for the delay, the man pulled out a large carving knife.

The encounter left Buttrick with post-traumatic stress disorder.

The National Health Service is spending more on healthcare than ever before, grappling with the costs of an ageing population. Wait times in the A&E are increasing, while the government’s austerity programme has meant less money for social care . But one of its largest challenges has been staffing.

“We’ve had a record amount of nurses actually leave,” Buttrick said. “We’re taking on cases we’re not equipped to handle.”

Overworked and under pressure, healthcare workers in the UK are leaving the National Health Service for other opportunities. According to numbers from NHS Digital, the health service lost about 10% of its nursing workforce three years in a row, or roughly 33,000 nurses in 2017 alone. The British Medical Association found that as many as three-quarters of medical specialties are facing shortages.

And the number one reason they’re citing for their departures? Better work-life balance.

A LinkedIn survey of nearly 1,000 UK-based clinicians, conducted in November, found that only 25% of doctors and 41% of nurses and midwives feel like they have a high level of work-life balance. Moreover, healthcare professionals employed outside the NHS were most likely to feel like they had good work-life balance (46% of respondents with no NHS involvement compared with 30% of NHS employees.)

Asked about why they left, more than half of respondents (56%) cited work-life balance as the reason for their departure, making it the top reason ahead of money, which was cited by just under half (46%).

Prime Minister Theresa May earlier this month released the government’s Long Term Plan for the NHS, including more than ￡570 billion for cutting-edge technologies, genomic research and a greater emphasis on preventative and primary care. Critics of the plan, however, say that it will be difficult to execute if the health service cannot solve its staffing shortages .

The NHS has said it needs to hire thousands of doctors, nurses and midwives across the country — and the need could get more dire as the United Kingdom prepares to leave the European Union. When the British Medical Association in 2017 surveyed 1,720 doctors from across the European Economic Area, 45% said they were considering leaving the country. Doctors from other European countries comprise about 9% of the NHS workforce.

Even some clinicians with British citizenship are concerned about the future, as reports have already surfaced about drug supply shortages and price increases. The UK government has encouraged drug manufacturers to stockpile at least six weeks worth of drugs in the country.

“All these things are scaring people, especially healthcare professionals,” said Jonathan Jones , a senior staff nurse at Guy’s and Thomas’ NHS Foundation Trust in London. “It’s like the Titanic. … Sensible people are actually thinking of the consequences of staying.”

The NHS could not reached for comment.

When asked what it would take to fix the NHS’ recruitment challenges, survey respondents overwhelming selected higher pay (75%), followed by bringing back bursaries for nurse and midwifery training (53%) and fostering better work-life balance (46%.)

The starting salary for fully-qualified nurses is just over ￡22,000 , rising to about ￡35,600 for a more senior position as a nurse leader on Band 6. Specialty doctors at NHS England , meanwhile, earn somewhere between ￡39,000 and ￡72,840. Consultants have a basic salary of about ￡78,000 to ￡105,000.

The NHS removed the bursary for student nurses and midwives two years ago, a decision that has been linked to a drop in applications to those programs by as much as a third. Nurses once justified lower wages because they were graduating with only a small amount of debt — but that’s no longer the case.

“They see the pay and say, why should I pay for a degree when I can do literally anything else?” Jones said. “I think they like to think of us as super-altruists. It’s a shame what’s happened, really. And if they’re going to pay so little, they should pay for bursaries.”

Filling positions with foreign grads

To help stem the shortage, the government has loosened visa rules and immigration caps to bring more foreign-trained doctors and nurses into the country.

Yet in LinkedIn’s survey, there was limited support for bringing in graduates from outside the UK (8%) or loosening the process for licensing medical professionals who are credentialed abroad (17%.) In open-ended responses, survey respondents cited concerns about differences in quality among institutions abroad as well as the need to maintain the NHS’ reputation and brand. They also pointed to the need to ensure proficiency with the English language.

Yet even if the health service can solve its recruitment challenges, retention remains an issue.

In high-cost London, it can be hard to find nurses willing to work for low salaries. The staffing shortage ripples through all ranks. When floor nurse jobs are so hard to fill, there can be reluctance to move people into nurse practitioner or nurse manager positions, Jones said. Nurses can get stuck in a role, unable to advance.

“They don’t have adequate career progression,” Jones said, “as opposed to our medical counterparts who actually have a pathway.”

Those feelings of being unable to advance were a unique pain point for nurses in LinkedIn’s survey, with nurses almost twice as likely as doctors to cite “opportunities for advancement” as a key factor that impacts recruitment and especially retention.

“It’s very much a situation of dead man’s shoes,” said Buttrick, the mental health nurse. “You’re put in a job and you’re not actually given the training you need to get to the next role. So people get stuck in a rut. Because of the way the NHS works, your skills become very specialised.”

A culture shift that began two decades ago

To Dr. Umesh Prabhu , a medical director and consultant paediatrician at the NHS, the change started to occur in the 1990s. That’s when reports began to surface that as many as 700 patients were waiting more than a year to see a specialist. Managers began to push heavily to reduce wait times, a noble goal that changed the work culture to one that was much more numbers-driven and high-pressure.

“The pressure creates the culture,” said Fred Coutin , an agency nurse in Manchester who has worked with the NHS on initiatives related to better work culture. “They transfer the pressure with stress, not support. Instead of leading by example, they lead by shouting and yelling.”

Managers in the past also tended to be promoted based on seniority rather than skill, he noted, but added that the NHS more recently has made additional investment into management training programs.

Possible solutions

Yet the retention challenges start early, well before doctors are considering leadership roles. In a paper published in 2017, Dr. Irene Gafson and her colleagues found that as many as 20% of trainees in obstetrics and gynecology drop out of the program while as many as 80% had seriously considered it.

“If you have that many people considering leaving, you’re going to end up with a workforce crisis,” she said.

Their study echoed LinkedIn’s findings: low morale, poor work-life balance, a lack of support and an overwhelming amount of paperwork that needs to be filed as part of the licensing process were top contributors to rising attrition. While most of these doctors-in-training choose another speciality, some leave medicine entirely.

Gafson’s program is now trying a number of approaches to support trainees. Junior doctors are matched with a local consultant who serves a mentor when issues arise. Senior doctors are encouraged to provide ongoing feedback — positive as much as negative — instead of only addressing areas of concern. And in an attempt to normalise feelings of wanting to drop out of the program, trainees are asked about whether they’ve considered leaving during their appraisals.

If they show signs of struggling, the program might suggest a part-time schedule. “The people who were happiest and least likely to leave were those with part-time jobs,” Gafson said.

Prabhu pointed to the need to fix what he described as the bullying culture at NHS and decrease workloads to reduce stress. But he emphasised that’s not just about working less, but giving clinicians time to think about challenging cases or pursue research projects.

“Today at NHS, doctors are not in any decision-making position,” he said. “It’s not just the working hours — it’s the support they have while they’re working.”