Is the NHS ready for a four day week?

Would staff value a four day week?

The NHS struggles to attract and retain health professionals. A 2022 BMA survey of 4500 resident doctors in England found that 79% often thought about leaving the NHS. The most cited reasons were low pay and its erosion since 2008, deteriorating working conditions, and increased workload—each mentioned by over 75% of respondents.14 These findings are confirmed by subsequent surveys15 and are common across Europe.16

In real terms, NHS staff wages remain lower than in 2010 (9-11% for doctors and 8% for nurses).17 This is a serious concern for staff, as demonstrated by the ongoing pay disputes. Raising wages enhances retention through better morale and financial security. However, it carries a substantial financial cost and, on its own, won’t alleviate overwork and burnout among professionals. Even its efficacy as a tool to improve retention has been questioned. 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.18

The four day week might be an acceptable, complementary solution to wage increases or other interventions. If implemented without proportional salary cuts, it raises hourly pay. Additionally, poor work-life balance is now the most common reason for leaving the NHS apart from retirement.19 In the past decade, voluntary resignations because of health rose by 189% and for work-life balance by 163%. Resignations attributed to poor reward package increased by 94%.20

Shortening the working week and the consequent work reorganisation is complex, particularly in tertiary care, but there is evidence that workers would value it. More so for two reasons. First, reducing hours doesn’t prevent staff who prioritise increased income from monetising their free time with extra shifts. Second, women are more likely to seek part time or flexible roles—often with lower wages and slower promotions. Given that women make up nearly 90% of nurses and midwives and most doctors registered to practise in the UK,21 healthcare workers may be particularly receptive to this model.

While a four day week is likely to be valued by staff on average, its impact across different NHS staff groups and teams remains untested—an important evidence gap. The potential value and risks to the service as a whole also need to be considered (fig 1).

Could the NHS benefit financially?

A four day week could benefit the NHS in several ways, although more evidence is needed to resolve uncertainty. Stress from intense workloads contributes to absenteeism and staff turnover,1415 which undermine service quality and impose a financial burden through reliance on agency and bank staff (costing NHS England £10.4bn in 2022-2322). It also increases the cost of training doctors and nurses in service.23 In 2011, 71% of foundation stage 2 doctors progressed into specialty training posts, but by 2019 that number had halved to 35%,24 effectively doubling the training cost for each new specialist in post. The link between fatigue and errors is also well documented.25 Errors in the NHS can have serious implications for patient safety, cause secondary problems that further increase workload, and entail a financial burden through legal costs and compensation of clinical negligence claims (estimated £6.6bn in 2022-2326).

In previous studies of four day weeks, workers reported improved wellbeing, more rest, and reduced stress and burnout.56 Participating companies reported increased productivity, lower absenteeism and turnover rates, and enhanced personal efficacy, with employees making fewer errors.34 This evidence is merely suggestive. We need robust evidence on whether it could reduce absenteeism, staff turnover and attrition, and medical errors in the NHS context, and generate savings. We note that an increase in staffing may be needed in areas facing shortages, to avoid gaps in complex staffing rotas adding pressure on remaining staff, or if productivity per hour doesn’t increase sufficiently, potentially offsetting those savings.

Could the NHS become more productive?

Studies indicate three key pathways through which productivity might increase, including onboarding efficiency, task reorganisation, and technology adoption.234 Employees are rarely at peak efficiency when starting a new role as they need to become familiar with institutional procedures, IT systems, patient needs, and team dynamics. High staff turnover or reliance on agency workers means many employees never reach optimal performance. It also entails workload associated with recruitment and mandatory training, which constitute a productivity loss to patient facing activities.

Productivity extends beyond individual efficiency. It is a team concept, influenced by how work is organised, coordination and communication among workers, the allocation of time and resources in work processes, and the effective use of technology. Changes in NHS processes can be difficult to implement: they are often perceived as cost cutting, and many workers view them with scepticism, fearing negative effects on their professional and personal lives.27 Studies suggest that four day week polices might incentivise workers to contribute to reorganising workflows, streamlining processes, identifying waste, improving task allocation, and adopting new technologies or AI.234 Although such initiatives can be pursued independently, the four day week might complement them, acting as a catalyst—helping to secure employee buy-in and facilitating broader changes.

However, these benefits depend on the identification of opportunities to create efficiencies through work reorganisation or technological adoption. Similarly, the benefits of recruitment efficiencies can be realised only if staff are retained. While both are possible, only formal testing can establish their size, and compare the effects with other interventions.

Evidence required to evaluate four day week

Rigorous evaluation is essential for any major organisational change—especially in healthcare, where lives are at stake. Existing evidence suggests that a four day week is worth testing in the NHS to assess whether it is acceptable, feasible, and cost effective.28 Given the complexity of healthcare delivery, a realist evaluation allows for an in-depth exploration of how specific mechanisms (such as a reduction in weekly hours) lead to particular outcomes (such as improved retention, reduced stress, or lower absenteeism), and how these effects vary by local context—such as staff group or care setting.13Figure 2 outlines a three stage approach.

Fig 2

Staggered realist evaluation of the four day week in the NHS

Establishing feasibility is a critical first step.29 An acceptability and feasibility study should gather insights into the expectations and preferences of key stakeholders. Mixed-methods data collection among staff would explore perceptions of a four day week in relation to pay, its practicality and desirability, and expected barriers. A survey of managers could assess their willingness to test the model. The study should identify key indicators to be evaluated and viable implementation models—such as staggered shifts, annualised hours, or nine day fortnights—and consider how they might interact with existing rota systems.

Depending on the results, the evaluation could progress to time limited pilots. Insights from the initial phase should inform which settings and staff groups are best suited for testing. Although it may be easier to trial in primary care, the potential gains are lower—nearly 80% of GPs already work less than full time.30 For many, this work pattern has been adopted to reduce the risk of burnout and still involves substantive unpaid hours. However, in this context a four day week would more closely resemble a pay increase or shift reorganisation. By contrast, secondary and tertiary care settings, though more complex, allow for evaluation across a broader range of staff—including nurses, doctors, and allied health professionals—and across functions such as elective and acute care.

Early engagement with interested hospitals could help identify appropriate departments and staff groups to pilot the approach and encourage conversations on how teams might adapt tasks, shifts, and responsibilities to maintain continuity of care. Rather than applying a one-size-fits-all approach, introduction of the four day week should be seen as a service redesign applied to most staff within selected teams, while allowing for role specific flexibility. Many staff in both primary and tertiary care—particularly nurses and other shift based roles—already work part time, compressed hours, or flexible patterns, and any pilot would need to account for these existing arrangements. Box 1 outlines an example with nurses in surgical wards in two Swedish hospitals. Temporary financial support may be necessary during the pilot to safeguard service delivery.

Pilots offer a low risk, cost effective way to determine any negative effects. If a pilot fails with willing leadership and expert guidance, broader implementation is unlikely to succeed. Pilots also help to understand the influence of human resources policies—such as overtime, extra shifts, annual leave, and student training programmes—as well as technological tools on pilot outcomes.

The findings should be evaluated by a multidisciplinary team of researchers, policy makers, and senior staff, with patient representation. If outcomes are positive, the final stage would involve formal trials. The intervention could be tailored to specific staff groups or departments and adapted to local contexts, as expected in any national rollout. Randomising a diverse range of hospitals to the intervention or routine practice, or to the timing of the intervention’s start, would offer the highest methodological standard.

A four day week poses potential risks, including benefits failing to materialise, inflated costs from additional hiring, and social norms obstructing successful implementation. These alone aren’t arguments against testing a strategy that may offer substantial benefits, as long as the trial has ethical approval. A trial that shows a four day week is too complex or prohibitively costly will shift the evidence base. Similarly, positive results won’t necessarily justify immediate system-wide adoption. The risk of a trial lies mainly in potential disruptions to care at participating sites. These risks—even in time limited pilots—can be mitigated through careful design, expert technical support, access to supplementary funding for additional staff if needed, and a trial safety monitoring board to intervene promptly if service quality or safety declines.

One of the NHS’s greatest strengths is its reliance on evidence based medicine to make cost effective decisions. The same rigorous approach should be applied to the organisation of work.