A BMJ article explores whether a four-day working week could ease recruitment challenges, reduce absenteeism, and improve morale in the NHS
As the NHS grapples with staff shortages, high turnover, low morale, and rising absenteeism, a new BMJ article asks a provocative question: Is the NHS ready for a four-day working week? The piece examines whether condensing work hours could help retain staff and sustain care quality, while also weighing the operational challenges such a shift would bring.
The much-debated four-day work week
Four-day weeks have grown in popularity, with evaluations of this schedule across several countries and sectors reporting benefits for both workers and employers. However, many supporting studies were conducted in self-selecting organisations, often without a control group, and many sectors also lacked the unique characteristics of the NHS.
There is sufficient promising evidence that a four-day working week would benefit the NHS, but rigorous research is necessary. BMJ researchers suggested using a realist evaluation approach to answer what mechanisms make it effective, which staff groups or departments benefit most, and what workplace settings or policies make it succeed or fail.
Would a pay rise boost NHS worker morale?
The NHS is struggling to retain its workforce, with many healthcare workers leaving the sector altogether. One 2022 BMA survey of 4500 resident doctors in England found that 79% often thought about leaving the NHS. Reasons include low pay and its erosion since 2008, as well as working conditions and increased workload.
Ongoing strikes across the UK highlight the frustration felt by NHS staff regarding their pay. Raising wages boosts retention through better morale and financial security, but it carries a substantial economic burden and does not alleviate overwork or reduce burnout.
A 2024 study, analysing NHS data from the past decade, found that a 10% increase in wages increased staff’s willingness to work full time by only 0.8%, concluding that pay is a necessary but not sufficient solution to its crisis.
This could be where a four-day working week might be a solution. If implemented without salary cuts, it raises hourly pay and improves work-life balance, which is a common reason for resignation from the NHS.
Shortening the working week and reorganising workload is complex, but it could provide added value for two reasons. Firstly, cutting working hours doesn’t stop staff who want to earn more from using their extra time to take on additional shifts. Secondly, women, who make up almost 90% of nurses and midwives, as well as the majority of doctors in the UK, are more likely to seek flexible or part-time roles, which can come with lower pay and slower career progression. This means that healthcare workers, in particular, may be especially open to the idea of a four-day working week.
The impact of a four-day work week remains untested across NHS staff groups and teams, which is a crucial evidence gap necessary for the condensed working weeks.
The risk of a shorter working week in the NHS
Implementing a four-day workweek in the NHS carries several potential risks. Reducing the number of working days could increase workloads on remaining days, leading to staff fatigue and a higher risk of burnout.
Operational challenges may arise, as significant adjustments in scheduling and staffing could disrupt workflows and affect continuity of patient care. Equity concerns are also notable, since not all staff may benefit equally; part-time workers or those in certain roles might see fewer advantages. Additionally, financial implications such as temporary staffing or overtime costs could offset anticipated savings, making careful planning and evaluation essential.
Four-day week case study in healthcare
In Sweden, two acute surgical wards at Vrinnevisjukhuset and Linköping University Hospital in Östergötland launched a two-year pilot to test a reduced working week, involving around 300 nurses.
One ward had nine operating theatres and the other about 20, covering orthopaedics, general surgery, urology, gynaecology, and thoracic procedures. One hospital relied on agency staff during weekends; the other operated entirely with employed staff, occasionally supported by retired workers. In the thoracic and vascular surgery unit, both elective and emergency procedures were supported by teams, including perfusionists, with 24/7 on-call cover.
The pilot aimed to address high sickness absence, staff retention issues in full-time roles, and concerns about long-term career sustainability. Weekly hours were reduced by 11% from 38.25 (or 37 for healthcare assistants) to 34 hours, with no pay cuts.
To participate, staff were required to work full-time and be involved in rotating shifts. Around 20–30% of staff were part-time before the pilot; many increased their hours to qualify, partially offsetting the hour reductions of existing full-time staff.
The initiative was voluntary and designed as a team-based transformation rather than an individual perk. It required careful rota planning to maintain service continuity. In Sweden, staff collaboratively create their own schedules using software, with central validation ensuring adequate coverage.
During the pilot, staff shifts and clinical hours remained unchanged, but “scheduled recovery time” was introduced, allowing employees regular, protected time off without being on call. No new staff were hired; modest cost increases arose as part-time workers extended hours.
Framed as a workforce sustainability strategy, the pilot improved staff wellbeing, work-life balance, and retention. Managers reported fewer rota gaps, lower overtime costs, and better continuity of care, with total surgical hours actually increasing. The pilot has been extended for another year, with external evaluation ongoing, and a similar program is being considered in Stockholm.
