Intended for healthcare professionals


The NHS workforce crisis is a retention crisis

BMJ 2023; 380 doi: (Published 14 March 2023) Cite this as: BMJ 2023;380:p602
  1. Malinga Ratwatte, GP registrar
  1. London

Pay cuts, worsening conditions, and an inability to provide high quality care all threaten the retention of doctors, writes Malinga Ratwatte

The NHS is in the grip of chronic workforce shortages. This fact is plain to see for people working in the service and makes the daily working lives of staff increasingly difficult.

Data from NHS England show that more than 9000 medical posts in secondary care were vacant in September 2022.1 In primary care, England has lost the equivalent of around 2000 fully qualified full time GPs since 2015. Yet the problem isn’t simply that there aren’t enough doctors to staff the NHS.2 It’s that there aren’t enough doctors willing to come to work in poor working conditions for artificially suppressed wages—all so that they can provide care that doesn’t meet the standard they wish to uphold.

The workforce crisis is also a retention crisis. More doctors are seeking alternative employment, going overseas, having a break from medicine, or taking early retirement. For example, the percentage of foundation year 2 doctors going straight into training in 2010 was 83.1%, but this was drastically down to 35% in 2019.3 From 2007 to 2021 the number of doctors taking early retirement from the NHS trebled, from 401 to 1358.4 And some of the doctors still working are increasingly choosing to stay at home to spend time with their loved ones instead of picking up extra shifts, after 15 years of real terms pay cuts and punitive pension taxes.5

In many NHS hospitals, locum pay caps that have been introduced to suppress payroll expenses discourage doctors from taking extra shifts. Economic theory tells us that when a price ceiling is created below the market equilibrium, excess demand and a supply shortage—of labour in this case—will follow. This contributes to the idea that “there are no doctors to come in and work to fill the rota gap,” and I welcome the BMA’s “scrap the cap” campaign to lobby against this practice.6

Consistent policy failure

Healthcare systems around the world are under pressure after the covid-19 pandemic, and the recruitment and retention of healthcare workers is a global challenge.7 Yet the way in which the NHS is struggling can be explained only by consistent policy failure.

In contrast with what we’re hearing from politicians, creating extra medical school places isn’t going to fix the crisis8—it’s like opening the tap further when you’ve got 10 holes in the bucket. What we need is for doctors’ real terms pay to be restored to what it was before the government started slashing the salaries of public sector workers. The real terms pay of junior doctors has decreased by 26% since 2008-09.9 If the government is serious about retaining staff so that the UK can run the high quality health service that patients deserve, then the wage erosion borne by healthcare workers for more than a decade needs to be fixed.

Junior doctors in England have taken industrial action from 13 to 15 March in their campaign for pay restoration. But what they’re asking for is even less than what previous generations of junior doctors had before 2008: the free hospital accommodation and more favourable pensions their predecessors enjoyed are now long lost. These benefits used to be mitigating factors when stacked up against junior doctors’ constant need to relocate geographically as part of training programmes. Now that those benefits are gone, and with the country in a cost of living crisis, doctors are asking themselves why they should undergo a training path that puts undue pressure on their relationships and family support structures.

It’s no wonder that doctors have had enough. Working in environments where it’s now normal for sick patients to be unable to get an ambulance within four hours—let alone see a doctor—leaves doctors in a constant state of stress. The transference of distress and anger from frustrated patients and family members to clinical staff, combined with the high intensity workload, is harming doctors’ mental health. There’s an emotional cost here that factors into the cost-benefit analysis when doctors decide whether to pick up an extra shift or, more fundamentally, carry on working in the NHS at all. Providing good quality care and helping people was often a driving factor for doctors entering the profession, but the inability to fulfil this social contract is now a price too high for many.

No doctor wants to spend their time on a picket line instead of treating patients, and it’s a shame that it’s come to this. But there are only so many repeated calls and ignored requests for negotiation that a profession can make before escalating the steps its workers take. Doctors have no other choice. The continued existence of the NHS as we know it is contingent on doctors’ success in campaigning for pay restoration. If the government fails to recognise this, talk of the “NHS crisis” may take on an even more desperate meaning in the years ahead.


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.