https://orcid.org/0000-0001-5717-1001
Abstract
To understand senior clinicians’ current thinking regarding retirement at a large teaching hospital trust, the reasons behind it, and what the trust can do to improve retention of these valuable staff.
An anonymized survey followed by qualitative study from a focus group. Data from these were analysed using a thematic analysis. Participants were senior clinicians currently employed or who had taken retirement from the trust in the preceding 12 months. In total 140 respondents completed the survey, giving a response rate of 65%; 8 senior clinicians attended the focus group.
The commonest reasons for taking retirement were wanting to pursue leisure interests, reaching a pensionable age, and feeling unable to sustain their workloads. A significant proportion, 29%, also cited that they did not feel valued. The commonest factors that would encourage respondents to remain at work included increased flexibility, reduced hours, and ability to come off on-call rotas. The main themes from the focus group were focusing on well-being, personalized conversations, and better/more accessible information.
Our project identified a number of reasons why clinicians are considering taking retirement, with a major theme of feeling valued underpinning decisions. This could influence strategies to help retain these experienced members of staff. We made a series of recommendations. If enacted, these would have a wider-reaching impact on more junior medical staff, aiding them to consider their own late-stage careers. They are also applicable and could easily be adapted when considering retention of other valued professionals within the trust.
What is already known on this topic—We know that there is currently a medical workforce crisis at a time of greatest patient need, with an ageing workforce and senior staff who are choosing to retire early. Previous studies have reviewed the reasons behind these decisions but not specifically looked at changes that can be implemented at a local level to improve retention.
What this study adds—We combined both quantitative and qualitative data from senior clinicians at a large teaching hospital trust in the North of England to understand current thinking regarding retirement and what the trust could do to improve their retention.
How this study might affect research, practice, or policy—From our study we were able to make a series of recommendations that can be implemented at a local level to inform medical retention policies. These will also have wider impacts on junior medical staff and could be expanded to other healthcare professionals.
Introduction
The National Health Service (NHS) is facing a very real workforce challenge and there is a huge demand for quality healthcare from an ageing population. Over the next 15 years, the number of people over 85 years old in the UK will increase by 55% [1]. Overall numbers of medical staff in hospital and community services have increased, and are 26% higher than 5 years ago. However, the vacancy rate is concerning at 5.7% [2].
As well as there being concerns about vacancies, the current workforce is ageing. Approximately 22% of medical staff are aged 50 years and over and 12% are over the age of 55 [3]. Additionally, doctors are choosing to retire early. From 2007 to 2021 the number of doctors taking early retirement from the NHS trebled, from 401 in 2007–8 to 1358 in 2020–1 [4].
The NHS Long Term Workforce Plan builds on the seven elements of the NHS People Promise and the NHS People Plan to improve staff experience [5, 6]. A key component of the NHS Long Term Workforce Plan to grow the medical workforce is to support current NHS staff, with aims to reduce the overall leaver rate for NHS staff from 9.1% in 2022 to between 7.4% and 8.2% [1].
Several studies have employed different research methods to identify reasons why clinicians consider retirement, with some similar overarching themes including feeling valued, work–life balance, and poor relationships with management [7–12].
A survey carried out by the British Medical Association as part of its Supporting an Ageing Workforce report identified factors contributing to a decision to retire and also asked participants about what would encourage working beyond retirement age. These included flexibility and better workload [13].
Our study was designed using both a survey and qualitative study from a focus group to gain a more in-depth understanding. We were also interested in what clinicians on the ground felt that the trust can do regarding these concerns and ultimately to retain them in post for longer.
Project aims
In this project we aimed to understand the following:
Senior clinicians’ current thinking regarding retirement.
What, if anything, the trust could do to encourage them to remain working for longer.
Materials and methods
Survey
In January 2024, we sent out a survey to senior clinicians at our trust. We contacted clinicians directly by e-mail with an invite to complete an online survey anonymously.
We purposely aimed to target staff members aged 55 years and over. As we were unable to access information on doctors’ ages, we identified staff using recorded General Medical Council (GMC) numbers and sent the survey invite to those with GMC numbers below 4 000 000. In total we sent the survey to 200 medical staff. We also asked clinical leads to forward a very similar survey to 15 members of staff who had retired from the trust in the preceding 12 months.
Reasons for considering retirement in currently employed clinicians
Reasons for taking retirement in retired clinicians
Codes, subthemes and final themes.
| Themes | Subthemes | Codes |
|---|---|---|
| 1. Focusing on wellbeing | Feeling valued Moral injury | Duty Patient care Workload Support Value Burn out Worth |
| 2. Tailored conversations | Conversations with the right person Individualised approach Targeted invitation | Personalising What would work for you Tailor the package |
| 3. Better and more accessible information | Work models Knowledge about your options | Options Patterns Models Rules Information |
| Themes | Subthemes | Codes |
|---|---|---|
| 1. Focusing on wellbeing | Feeling valued Moral injury | Duty Patient care Workload Support Value Burn out Worth |
| 2. Tailored conversations | Conversations with the right person Individualised approach Targeted invitation | Personalising What would work for you Tailor the package |
| 3. Better and more accessible information | Work models Knowledge about your options | Options Patterns Models Rules Information |
Codes, subthemes and final themes.
| Themes | Subthemes | Codes |
|---|---|---|
| 1. Focusing on wellbeing | Feeling valued Moral injury | Duty Patient care Workload Support Value Burn out Worth |
| 2. Tailored conversations | Conversations with the right person Individualised approach Targeted invitation | Personalising What would work for you Tailor the package |
| 3. Better and more accessible information | Work models Knowledge about your options | Options Patterns Models Rules Information |
| Themes | Subthemes | Codes |
|---|---|---|
| 1. Focusing on wellbeing | Feeling valued Moral injury | Duty Patient care Workload Support Value Burn out Worth |
| 2. Tailored conversations | Conversations with the right person Individualised approach Targeted invitation | Personalising What would work for you Tailor the package |
| 3. Better and more accessible information | Work models Knowledge about your options | Options Patterns Models Rules Information |
Survey questions
Demographic information: age, gender, nationality, disability
Planned (or actual) retirement age
Reasons for retiring/considering retirement. Respondents were asked to give one or more reasons:
Reached pensionable age
Reached an age where you can retire comfortably financially
Due to pension tax changes
Ill health
Do not feel valued or well supported
Wanting to pursue leisure interests and spend time with family
Do not feel you can sustain workload or being on-call
Lack of flexibility, reduced hours, breaks, or leave
Lack of autonomy and respect
Other
If there is anything that would encourage them to consider remaining at work
Whether they were considering retiring and returning.
Focus group
Respondents to the survey were asked to provide their details if they were happy to be contacted to discuss their thoughts regarding retirement in more detail. Out of the 62 who left their details, 8 were available to attend a 2-hour in-person focus group.
The aim of this focus group was to gain a better understanding of reasons behind retirement decisions and what actions the trust could take to encourage them to remain at work for longer.
Written consent was obtained prior to participation in the focus group. The participants provided an overview of their personal experiences. Results of the survey were presented followed by facilitated discussion around the aims of the project: understanding reasons for retirement and what could encourage clinicians to remain at work.
Participants included current members of staff working full time, those that had retired and returned, and one participant who had fully retired.
The session was audio recorded and anonymized through the transcription process. Notes were taken to ensure all information was accurately captured.
Data analysis
Alongside an analysis of the survey data, thematic analysis was conducted for the focus group as described by Braun and Clarke [14]. The audio-recorded session was transcribed the day after the focus group. This transcription was then read and reread by the first author to familiarize themselves with the data. Following the six steps of thematic analysis, initial ideas were generated, coded, and then organized into themes [15, 16].
Patient and public involvement
Patients were not involved in the design or conduct of this study.
Ethics
Prior to contacting any staff regarding the survey or focus group, the project was presented to the research and innovation team at our trust who advised that it did not require ethical approval, therefore this was not sought.
Results
Survey results
Out of the 200 clinicians currently employed by the trust, 133 completed the survey, giving a response rate of 66.5%. Out of the 15 clinicians who had recently retired, 7 completed the survey, giving a response rate of 46.7% in this group. Of the total of 140 respondents, 134 were consultants, whereas the remaining 6 identified themselves as Specialty and Associate Specialist (SAS) doctors and medical examiners. In terms of gender, 48 respondents were female and 92 were male. Respondent age ranged from 54 to 73 years. Median planned age of retirement was 60 (range: 55–75) years, and for those who had retired the median age was also 60 (range: 54–67) years. Of respondents, 41% were considering taking up the retire and return option and 71% of those recorded as being retired had taken this up.
Reasons for considering retirement (133 respondents)
Respondents were asked to complete one or more options regarding their reasons for considering retirement. The commonest reasons were wanting to pursue leisure interests and spend time with family (n = 74; 56%), reaching a pensionable age (n = 66; 50%), and feeling unable to sustain their current workload (n = 62; 50%); a significant proportion also cited that they did not feel valued or supported (n = 38; 29%).
Reasons for retiring (seven respondents)
For those that had already retired the results were comparable although the numbers were small. The commonest reasons cited for retiring were having reached a pensionable age (n = 6; 86%), wanted to pursue leisure interests and spend time with family (n = 4; 57%), and felt that they were able to retire comfortably financially or felt that they were unable to sustain their current workload or being on-call (n = 3; 43%, each). Again, a proportion of respondents cited that they did not feel valued or well supported (n = 2; 29%).
Factors that would encourage staff to remain at work
For current members of staff, the commonest comments concerning factors that would encourage them to remain at work included increased flexibility with regards to work and annual leave, reduced hours, and the ability to come off on-call rotas. A significant proportion also commented on feeling a lack of respect and support, raising a concern about the general well-being of clinicians. For those who had already retired, the majority indicated that there would not have been anything the trust could have done to encourage them to remain at work for longer. Of the respondents that did comment on what the trust could have done, increased flexibility, improving the issues faced with pension tax, and improved clinical resources were cited.
Focus group
Participants were encouraged to discuss reasons for considering retirement and also what the trust can do to help those thinking about the later stages of their careers. Thematic analysis of the focus group recording transcription was performed to identify the main themes that emerged from the session: focusing on well-being, tailored conversations, and better and more accessible information.
Focusing on well-being
In general participants agreed with the survey results regarding reasons for considering retirement; however, they felt that these did not reflect the current state of clinicians’ well-being. There were several comments regarding this and their individual experiences.
Feeling valued
Feeling valued by both the trust as a whole and colleagues is important to clinicians’ well-being and professional identity:
‘I certainly got the feeling that I wasn’t worth keeping.’
‘I think if your colleagues are not valuing you, it really is hard to keep going.’
Feeling valued was also reflected in interactions with management, senior leadership teams, and also their working environment:
‘I put in for three different weeks in the summer holiday for annual leave and four separate random days…and the lot was refused…if you can’t book annual leave a year in advance…it was just the final straw.’
‘When [the Chief Executive] would come and visit the department and speak to us, he appeared to show a genuine interest in what we were doing. What was making life more difficult for us and what the trust could do to support our service. That was really genuine and I, for me as a consultant that helped massively.’
Moral injury
In 2021 the British Medical Association produced a report based on their review of moral distress in the UK medical workforce. In their report they describe two concepts, moral distress and moral injury, which are often used interchangeably [17].
Moral distress is presented as ‘the psychological unease generated where professionals identify an ethically correct action to take but are constrained in their ability to take that action’. Moral injury can occur when ‘sustained moral distress leads to impaired function or longer-term psychological harm’.
The clinicians in our focus group were aware of these concepts and also reflected that they had experienced them themselves:
‘The harm we suffer when we see our patients and think, we could be doing better, but we can’t… and we cannot provide the level of care that we’ve been taught to provide.’
‘My patients were suffering, and they were coming in with repeated emergencies or they couldn’t go to work, or they couldn’t have a family. All because I couldn’t do my job and that hurt, that’s why I burnt out.’
When participants were asked to discuss what the trust could do to help clinicians remain at work, open conversations and information dissemination were noted as key.
Tailored conversations
Starting from a ‘yes’ standpoint was presented as a positive experience by one member of the group. An important factor for all was the individualization of these conversations as it is clear that clinicians have different needs regarding their work and also individual specialties have different requirements:
‘I think the conversation should start, which mine indeed did, with what would look good for you.’
‘Just to hear once. You are really valued. We’d love to keep you. What can we do to keep you? I’d have probably binned nine out of ten of my whinges and if you could have tweaked, my one whinge I might have stayed.’
Better and more accessible information
Each of them reflected on an element of difficulty in finding out what could be available to them. They explained that they had sought out information individually or from colleagues; however, having something aimed at them directly would be beneficial:
‘It feels you’re stuck in your job plan. Or you retire. Or you leave… doesn’t appear to be anything in between.’
‘I’m aware to some extent of the rule changes, but I’m not aware of what work pattern I could work, could I have an annualized contract… information like that will be helpful. What can the trust provide.’
‘It’s having the knowledge and having different work models to say, well, this is for example, what we could do. Put a little package of these are examples of work models so that it helps inform the CD/ clinical lead and the person having the job plan.’
‘The idea of an invitation targeted towards people at an appropriate age where you might be thinking about this and knowing about your options and say templates, could be presented of patterns would be very helpful.’
Impact
It is clear from the comments that feeling valued underpins a lot of clinicians’ decision making with regards to the later stages of their career. Moving forward, anything that the trust does now to support clinicians towards the end of their career will have a wider-reaching impact on the medical workforce:
‘Whatever you do for us lot now, we will go away and say to our junior colleague... and they’ll go, “Oh well there is light at the end of the tunnel.” Whereas at the moment, they're all going, “Oh, what else can I do besides medicine?” So, it’s really important not just for us but to also feed down.’
Discussion
Whilst expansion of medical school places and increased recruitment of medical staff are needed to meet the growing needs of our patients, these will take time, so retention of medical staff is crucial, which has been highlighted for several years [18].
The GMC workforce report 2023 found that the proportion of doctors leaving the profession has returned to pre-pandemic levels; however, they presented concerns about a rising number of clinicians taking steps to leave the profession [19].
Although pay is important to ensure that staff are rewarded for their work, it is only a small part of what ultimately influences staff retention [20, 21]. In the NHS staff survey 2023, only 45% of staff indicated that they felt satisfied with the extent to which their organizations value their work [22]. Tackling well-being alongside appropriate remuneration for work is key [23]; this was also reflected in the GMC’s workplace experiences report [24]. Burnout was mentioned in both our survey responses and the focus group. The loss of social connectedness and its contribution to physician burnout has been studied. One paper concluded that to reduce the rates of burnout we must ensure that clinicians’ basic need of belonging is met by them experiencing rewarding connections with those they work with and for [25].
We acknowledge that our study represented a small sample size. The overall response rate to the survey was 65%; however, research has shown that the average response rate for healthcare professionals is 53.3%, suggesting that ours is a sufficient result to enable us to draw conclusions [26]. Although we only had a small number of participants in the focus group, it provided some useful insights and ideas. A lot of the comments in the discussion were also reflected in the free-text comments in the survey so we are confident that they do represent the feelings of senior clinicians.
Implications for practice
Based on participant suggestions from both the survey and focus group a series of recommendations for the trust were identified to try to improve medical workforce retention.
Invite senior clinicians aged 55 years and over to a voluntary meeting.
The correct forum for these conversations was felt to lie outside that of the annual job planning and appraisal meetings. It is particularly important that the correct members of staff are present to provide information on both what the trust could offer and also what could work practically in their department.
Create an information source including examples of what has worked in some departments for use by clinicians and clinical directors.
Up-to-date information with worked examples would be beneficial to clinicians and also their clinical directors, to share what is working in other departments and encourage more flexibility.
Formally recognize the legacy mentor role.
Offer legacy mentoring training to senior clinicians.
Recognize the role within senior clinicians’ job plans following completion of training.
The legacy mentor role is recognized in the NHS. Several organizations have successfully implemented legacy nurses with positive outcomes for both junior staff and the legacy nurses themselves [27]. Provision of training could ensure that this role is formalized and support recognition of it within clinicians’ job plans.
Offer drop-in sessions with senior management to discuss what is working well and what is working less well within departments.
Senior clinicians appreciate personal interactions with the senior leadership team regarding what is happening within their department. They often feel powerless with regards to challenges in providing high-quality patient care and report a high level of moral distress. Being able to discuss issues and understand the trust’s position on some of these may help to alleviate some of the personal harm clinicians are experiencing.
Provide peer support groups to individuals as a forum to discuss experiences.
The focus group for this project sparked a lot of conversation and participants fed back it was useful to share experiences with colleagues they would not normally have chance to. Provision of a similar forum could benefit clinicians and also help to share examples of what works in some departments.
Conclusion
The NHS Long Term Workforce Plan makes ambitious commitments to increase the workforce. However, some argue that it does not go far enough to address the issues regarding staff retention [28]. Whilst the implementation of the Long Term Workforce Plan is underway, it is clear that we must act now to try to improve staff retention. The recommendations developed in our study are achievable and aim to ensure that clinicians feel valued in their senior roles, which will have an impact on retention and patient care.
Acknowledgements
We would like to thank all the clinicians who took part in this study, for sharing their views and personal experiences as part of both the survey and also the focus group. We would also like to thank Alexander Booth who assisted with recording and taking notes during the focus group.
Author contributions
S.L., S.J., and H.M. developed and designed the study proposal. S.L. and H.M. recruited participants to the survey. S.L. and S.J. developed and conducted the focus group. S.L. analysed the data and wrote the first draft of this paper. S.J. commented on the draft and contributed to the final paper.
Conflict of interest statement: None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data availability
All data relevant to the study are included in the article.
Ethics approval and consent to participate
Leeds Teaching Hospitals Trust Research and Innovation team reviewed the study proposal and felt that it did not require ethical approval.
Consent for publication
Not required.
