A new IZA discussion paper by Marco Mello, Giuseppe Moscelli, Ioannis Laliotis and Melisa Sayli reveals the significant impact of contractual changes on the attrition of NHS trainee doctors. The 2016 reform of the NHS contract for junior doctors increased their base salary by 10.5%, but controversially reduced the pay for night and weekend shifts—referred to as “unsocial hours.” The findings suggest that these changes have had far-reaching negative consequences for both trainee retention and patient care in England’s National Health Service (NHS).
The shortage of healthcare workers has been a growing concern in many developed OECD countries, including the UK, where trainee doctors—medical graduates in their post-graduate training phase—are crucial for the continuity of the healthcare workforce. The proportion of NHS trainee doctors who transitioned directly into specialty training dropped from 71.3% in 2011 to 37.7% in 2018, raising alarms about the sustainability of medical staffing levels.
The 2016 contractual reform, which cut maximum weekend pay supplements from 50% under the 2002 contract to 15%, was aimed at rebalancing pay structures but has unintentionally exacerbated the loss of trainee doctors. An analysis of administrative payroll data from NHS hospitals found that the reform led to a 6.7% increase in the annual number of junior doctors leaving the NHS. Further insights from the NHS Staff Survey indicated that dissatisfaction with pay has become a significant factor in doctors’ intentions to leave the healthcare sector, with a notable rise in dissatisfaction since the contractual changes were implemented.
The consequences of increased trainee attrition are not limited to workforce dynamics—they extend to patient outcomes as well. By linking payroll data with patient admission and mortality records from NHS hospitals, the researchers examined how fluctuations in trainee numbers affected patient care. They found a positive association between the monthly attrition of trainee doctors and subsequent increases in patient mortality, particularly among emergency cases. The study used risk-adjusted metrics to ensure accuracy, accounting for confounding factors like patient age, co-morbidities, and seasonal variations.
The study highlights the crucial role of trainee doctors in the NHS—they serve as first responders in assessing patient severity and provide essential support to tenured medical staff. Reduced retention of trainee doctors therefore not only impacts staffing but also the quality of patient care, especially in emergency situations where timely assessments are vital.
The authors conclude that policy-makers must consider the implications of altering compensation structures, particularly when it comes to unappealing aspects of medical work such as unsocial hours. Changes that reduce incentives for these challenging shifts may undermine both staff retention and the quality of hospital services. The evidence suggests that careful design of pay schemes is essential to maintaining a robust and motivated healthcare workforce capable of delivering high-quality care.