James Watts, Consultant in Anaesthesia and Critical Care Medicine, East Lancashire NHS Trust, looks into working conditions and pay in the medical industry
2023 will be remembered as a period of almost unprecedented social and political unrest with strikes across the private and public sector, including the junior and senior medical staff, which at the time of writing are still ongoing, although a substantive offer is being considered by the consultant body(1).
The background to this was an extraordinary level of discontent amongst medical staff of all grades, centering on both working conditions and pay. (2)
The unrest came at a unique time: the country was still suffering the after-effects of the COVID-19 pandemic and the social and economic upheaval that had resulted. Following this, a variety of factors had contributed to a rise in inflation, followed by an increase in interest rates in a bid to control it, and an associated rise in the cost of living. It was Government policy to keep public pay sector wage increases low as a tool to control further damaging inflation. However, this led to public sector workers who had been on the frontline in the pandemic- including care workers, nurses, doctors, hospital staff, police, fire, paramedics etc- feeling undervalued; whereas the cap on so-called bankers bonuses was removed without issue; and Criminal barristers obtained a 15% across the board rise for funded defence fees following industrial action. (3-6).
As a result, one of the main grievances cited, particularly by so-called ‘junior doctors’ (a term that includes some highly skilled professionals with years of experience) was a relative reduction in pay over the years which had caused a recruitment and retention crisis. The workforce planning of the health sector is extremely complex, and factors other than pay had certainly contributed to this. Whatever the main cause, failure to appropriately expand staff numbers, and an increasing workload, were believed to be creating what was regarded as at best an unsatisfactory, and at worse a dangerous, working environment for staff and patients. (7)
As a result, it was reported that pay and working conditions were the main cause of doctors leaving the NHS and the UK after reaching a moderate level of competency, and moving abroad where the pay and working conditions were better. This information was spread widely on social media, and in 2023 the BMA began propagating the concept that over the years doctors had suffered a relative and increasing deficit in pay – greater than that of other health workers – due to the failure of the government to keep pay in line with inflation. The figure of a 35% deficit was widely suggested and became entrenched as a minimal pay demand in the minds of the media (8).
This analysis will not comment on politics, or whether NHS staff should or should not be able to strike; but will only concentrate on changes to wages since 2008.
Recommendations on pay are made by the Doctor and Dentist’s Pay Review Body (DDRB).
The Doctor and Dentists Pay Review Body
The Doctors’ and Dentists’ Review Body is a committee established in 1960 by Parliament in response to the Royal Commission of Doctor’s and Dentist’s Remuneration. It is sponsored by, but is not part of, the Department of Health (which means that the DoH provides infrastructure, supports its website and publishes its reports etc); and is independent of both Government and the profession.
In making its recommendations, the DDRB invites evidence from a range of stakeholders, including the BMA and the Government, and then provides a report as to how much doctors’ pay should increase in the following year. This is a recommendation only and whilst the Government can take this under advisement, it is free to ignore the recommendation when making an award through NHS Employers
The overriding principle of the DDRB is to provide some safeguard to doctors who effectively have a monopoly employer who also happens to be a monopoly producer, trainer and provider by matching doctors’ pay with other similar public and private sector jobs.
In reaching its recommendations, the Review Body is supposed to have regard to the:
- recruitment, retention and motivation, including the effects of regional & local variations in labour markets
- the funds available to the Health Department as set out in the Government’s Departmental Expenditure Limits
- the Government’s inflation target;
- the overall strategy that the NHS should place patients at the heart of all it does and the mechanisms by which that is to be achieved.
The Review Body may also be asked to consider other specific issues such as the economic and other evidence submitted by the Government, staff and professional representatives and others. The Review Body should also take account of the legal obligations on the NHS, including anti-discrimination legislation regarding age, gender, race, sexual orientation, religion, belief and disability (9)
In its evidence considered in 2022, the DDRB asserted that consultants pay fell on average between the 98 and 99th percentile for average UK earnings. Using the 5th point on the consultant salary scale as a marker, it was accepted that pay had decreased between 2003 and 2018; had held steady between 2018 and 2020; and had risen in 2021. It was asserted that the pay of registrars was consistently between the 90th and 92nd percentile; that of core trainees was between the 85th and 88th percentile; whilst that of year 1 Foundation Trainees sat between the median and upper quartile. Consultants’ median earnings were above that of the highest-paid veterinarians and higher education academics, but substantially lower than for finance and accounting, legal, pharmaceutical and comparable professionals.
Also taken into account for the 2023 recommendation was reported satisfaction with pay. Consultant satisfaction was 59.6% in 2021, a fall of 5.7% since 2020; for other doctors satisfaction score was 49.8% in 2021-reduced from 57% in 2020. They also noted the increased volume and complexity of the workload.
The role of the DDRB has been questioned in recent years given a perception that the Treasury can override their recommendations; and that the DDRB repeatedly allows the Government to miss deadlines for the submission of evidence. As a result, whilst inflation has increased, there is evidence that doctors’ income has been failing to match this, in effect falling over many years (10).
The role of His Majesty’s Government
The role of Government very simply is to manage the infrastructure of the whole of the United Kingdom for the benefit of the majority. This includes providing social safeguards (health, social services, emergency services, defence etc), a Law and Order framework (the Courts and the police), and the management of the public finances. This is not the forum to discuss the relative merits of a completely unregulated free-market economy or a completely centralised economy in achieving these goals: it is enough to note that there are conflicting and important priorities for any UK Government, and wide differences in opinion as to how these priorities should be met, some of which are political. Control of public sector expenditure (i.e. those services provided by, through, or on behalf of the Government for the UK public) is important in the management of aspects of the economy (11)
Is there a deficit in Doctor’s pay?
If we define a ‘deficit in pay’ as the difference between what pay would be now if wage increases had exactly matched inflation, and what it actually is, the answer is ‘yes’.
However, it should be remembered that inflation (the rate of cost-of-living increases) does not change uniformly year on year, but can increase or decrease at varying rates, dependent upon many factors which are outside Government control, and so pay awards that may match or exceed inflation one year may be regarded as inadequate or excessive the next.
To reduce the complexity in considering this question, an average rate of annual inflation since 2008 of 3.38% per year has been assumed (12): in effect an item costing £1 in 2008 would in 2023 cost £1.64 (although some sources cite a lower rate resulting in an item increasing from £1 to £1.56 over the same period – 13.)
A Freedom of Information request to the Department of Health in September 2023 (14) asked the following questions relating to the period 2008-2023:
- What have DDRB recommendations for pay increase for Drs of all grades been?
- What have the DoH/Government actually awarded them?
- How often has Gvt/NHSE missed the deadline for DDRB submission and had to request an extension?
This last question was not answered because the information was not available. However, the DoH provided detailed answers to the first two questions.
These are illustrated in the following tables. The tables include a comparison between the rate of inflation , the pay award, and whether pay awards were given or not.
As can be seen, the calculation of any deficit is difficult as: not all grades of doctor received the same pay award in any one year (some received none, some received a one-off unconsolidated payment, some received a one off consolidated payment); and not all doctors within the same grade received the same pay rise (sometimes those on the top increment for a particular grade were excluded).
An unconsolidated pay award is not carried forward into the next year, but is effectively a one off payment that does not increase base pay. A consolidated pay award is carried forward and does increase base pay. For example, a person on £30000 who receives an unconsolidated pay award of £1000, will still only receive £30000 per year the following year; those who receive it as a consolidated award will receive £31000 basic pay the next year.
The tables show:
- DDRB recommended pay awards have been generally less than the average rate of inflation across the whole period considered. However, this average does not take account of the change from relatively low levels of inflation long-term to high levels of inflation recently.
- When comparing to recorded levels of inflation for individual years, some of the pay awards recommended by the DDRB do not look unreasonable; and some of the actual pay awards do not look outrageous. However, the comparative negative changes to rates of inflation the tables mean only that prices are rising at a lower rate, not that they are falling. In addition, ‘keeping pace’ pay rises do not target retention as part of wage policy.
- Pay freezes were administered in 2011/12 and 2012/13 leading to a fall in wage compared to inflation.
- The divergence between DDRB recommendations and pay awards awarded by the Government began under the Conservative/Liberal democrat coalition in that the top increments of each pay scale began to be excluded from pay rises, or some awards became unconsolidated, or both. As a result, different grades of doctor have been affected differently by the last 15 years’ approach to pay increases; and different doctors within the same pay grade were also affected differently in that:
– A consultant who had been on top of the salary scale since 2008 would indeed be 35% worse off compared to pay keeping pace with inflation after the 2022/23 pay recommendation was implemented.
– A consultant not on the top scale would on average be 30% worse off than their equivalent in 2008.
-A registrar or staff grade would be between 31 and 32% worse off compared to inflation matching rises compared to their equivalent in 2008.
-A Foundation Doctor would be 31-32% worse off than their equivalent in 2008.
– The larger than usual pay rises awarded initially in the 2023/24 pay round make only a small difference overall to this deficit.
In a slightly different analysis, MPs have had a cumulative pay rise of 29% between April 2008 and April 2021. In real terms, in comparison to inflation, this equates to an 18% pay cut. In the same analysis, junior doctor’s wages over the same time period only equate to a 17% rise, and so they have experienced a much larger deficit than MPs. MP salaries have also risen at a faster rate than the rest of the public sector (15.)
This analysis is only one of many on the subject. However, it would appear that doctor’s salaries for all grades have not kept pace with inflation, leading to a deficit of 30-35% across the board when compared to what they would be had inflation been fully accommodated in pay awards. The pay for doctors remains in the top cohort of society, but lags behind that of many comparable professionals. This analysis is only one of several ways to look at the figures, and different final figures can be derived. However, there does appear to be a large difference between the pay rises awarded to doctors; and how pay would have increased had inflation rate pay rises been awarded. Pay correction on its own may not solve the ongoing manpower shortage; but it is one method of recruiting and retaining staff.
To download the following tables click here :
Table 1: Pay scale awards matched to Governing Political Party
Table 2: Pay recommendations and awards compared to annual inflation rate
Table 3: Conversion of DDRB award recommendation vs actual Gvt award 2008-2023 converted into monetary terms compared to: inflation of 3.38%
Goods costing £1 in 2008 would cost on average £1.56 in September 2023
2. Saber IF NHS strikes: What ails the NHS? Doctors’ protests or budget cuts? https://www.aljazeera.com/news/2023/10/2/nhs-strikes-what-ails-uk-health-service-doctors-protests-or-budget-cuts )
4. Fright M Davies N Richards G Retention in Public Services Institute for Government. 9/10/23 https://www.instituteforgovernment.org.uk/publication/staff-retention-public-services#:~:text=Societal%20norms%20have%20changed.,no%20help%20on%20the%20horizon
5 The Guardian UK financial regulators end cap on Bankers’ bonuses 24/10/2023
6. Casciani É Burns J Criminal Barristers vote to end strike over pay BBC News 17/10/2022 https://www.bbc.co.uk/news/uk-63198892
7. Thomas R Junior Doctors’ Strike: Why are they taking action and what are their demands? The Independent 4/01/2024 https://www.independent.co.uk/news/health/junior-doctors-strike-pay-salary-demands-b2473038.html#comments-area
8. BMA media team. BMA says that 3.5% pay recommendation is ‘more than insulting’ to thousands of NHS workers BMA press release 22/02/2023 https://www.bma.org.uk/bma-media-centre/bma-says-35-pay-recommendation-is-more-than-just-insulting-to-thousands-of-nhs-workers
9. Review Body on Doctors’ and Dentists’ Remuneration Fiftieth Report 2022 July 2022 https://assets.publishing.service.gov.uk/media/62d6c70cd3bf7f2859357c42/DDRB_2022_report.pdf
10. BMA Report into the Failings of the Pay Review Process for Doctors and Dentists https://www.bma.org.uk/media/6720/bma-report-into-the-failings-of-the-pay-review-process-for-doctors-and-dentists-2023-v2.pdf
11. Overview of the UK system of Government https://webarchive.nationalarchives.gov.uk/ukgwa/20121003074658/http://www.direct.gov.uk/en/Governmentcitizensandrights/UKgovernment/Centralgovernmentandthemonarchy/DG_073438
12. The British Pound has lost 39% of its value since 2006 CPI Inflation Calculator https://www.in2013dollars.com/uk/inflation/2008
13. Inflation Calculator Bank of England https://www.bankofengland.co.uk/monetary-policy/inflation/inflation-calculator
14. Personal communication: Department of Health Freedom of Information response September 2023
15. Garrie J How do junior doctor’s pay demands compare with MPs recent salary rises? Full Fact Check April 2023 https://fullfact.org/health/pay-inflation-mps-junior-doctors/