The pressure and impact analysis is an important process in integrated river basin management and a key procedural element of the EU Water Framework Directive. It aims to inform both the assessment of water body status and the development of management responses. However, the Directive does not provide prescriptive guidance on how it should be carried out and during the 1st river basin cycle, its application proved to be a real challenge. Incorporating ecosystem services as indicators of impacts, a participatory framework for pressure prioritisation is presented here. While various methods exist for engaging stakeholders in river basin management, the framework allows for the ecosystem approach to be operationalised through a risk assessment perspective, in the context of the pressure impact analysis. Applying this to a case study in England, we demonstrate how a ranking of pressures can be delivered based on stakeholders’ perception of how the delivery of ecosystem services is affected by each pressure and incorporating their value as indicator of the magnitude of the impact. This approach allows for a more systematic way to effectively prioritise significant pressures and therefore select appropriate programmes of measures in line with the Directive's integrated river basin management paradigm.