Executive summary

The NHS Hospital and Community Health Service (HCHS) in England directly employs around 311,000 full-time equivalent nurses and health visitors. These staff account for a quarter of all NHS staff and nearly half of NHS vacancies. In 2019/20, their pay bill accounted for nearly one-third of the overall NHS Agenda for Change staff pay bill of around £43.4bn. Better understanding of the pay determination process for NHS nurses is therefore crucial for informing policy on NHS nurse recruitment and retention, staff pay and, more broadly, funding.

In this report, we explore the method underlying this process of determining NHS nurses’ pay and its outcome in terms of nurses’ actual earnings, particularly in the NHS HCHS in England. Practice nurses and nurses working for non-NHS employers are not the primary focus due to a lack of relevant data. We also analyse long-term trends in UK nurses’ earnings, drawing on Organisation for Economic Co-operation and Development (OECD) data and stakeholder input for additional insights from international comparisons. Our goal is to generate evidence that provides insights into the long-term outcomes on nurses’ earnings, and highlights scope for potential improvements to the UK’s current approach to nurse pay determination.

There have been significant changes in NHS staff pay determination since the NHS was established in 1948. In the 1950s and 1960s, arbitration was frequently used to settle Whitley council disputes. In 1983, separate review bodies were established to streamline pay determination for NHS nurses and allied health professionals. Subsequently, these review bodies were merged to form the NHS Pay Review Body (NHSPRB), which has since made recommendations on pay increases for most NHS staff (except doctors, dentists and very senior managers) to the UK government, usually on an annual basis. Major landmarks in NHS nurses’ pay determination since the 1980s were the introduction of clinical grading in 1988 and the initiation of Agenda for Change in 2004. Clinical grading introduced a new pay structure which used job evaluation techniques to link nurses’ pay rates to their roles, skills and responsibilities, rather than merely their job titles. The Agenda for Change framework is characterised by harmonised pay scales and career progression systems across different NHS occupations.

We present analysis of long-term trends in UK nurses’ earnings, exploring how the changes in nurses’ earnings since the 1980s compare with inflation, all-employee average earnings and the average earnings of police officers and secondary teachers, two public sector occupations which provide useful points of comparison. NHS nurses’ earnings comprise basic and non-basic elements. Basic earnings generally account for over 80% of nurses’ overall earnings and over 90% of overall earnings for higher Agenda for Change pay bands. Non-basic earnings include additional components such as overtime pay, geographic allowances and shift work payments. The relative size of these components varies between different nurses and different pay bands. Our analysis focuses on basic earnings, for which trend data are more widely available. Due to data constraints, we do not examine non-basic earnings components and ‘total reward’ considerations (pensions and other benefits recorded in Total Reward Statements), although these are important in developing a fuller understanding of nurses’ compensation and labour market behaviour. We also do not consider the impact on nurses’ labour market participation decisions of other, non-financial factors such as childcare and other care support and flexible working.

Overall, female full-time nurses’ average gross weekly earnings doubled in real terms between 1988 and 2009. This was followed by the public sector pay cap period of 2010–2017 which led to a real-terms earnings decrease for nurses. This meant that female full-time nurses’ mean gross weekly earnings in 2019 were virtually the same as in 2008.

Taking inflation into account reinforces the point about the negative impact of the pay cap. NHS nurses’ basic earnings in England grew by 13% in nominal terms over the period from March 2011 to March 2021. After accounting for consumer price inflation, this amounts to a fall of 5% in real terms. Taking a longer term perspective, between 1989 and 2019 female full-time nurses’ real-terms weekly earnings grew by a very similar factor to overall full-time employee earnings in the UK.

When we consider comparable public sector occupations such as policing and teaching, our analysis shows that since 1989, female full-time nurses’ average real-terms weekly gross earnings have grown more rapidly than those of female full-time police officers and secondary teachers. This includes the public sector pay cap period.

This report also makes a crucial point about earnings trends analyses: the results can vary markedly depending on the choice of start year. For example, taking 1989 as a start date UK nurses’ average weekly earnings increased by 59% in real terms by 2019. However, if the start date for analysis is moved by one year to 1988, then the increase in earnings to 2019 was 94%. This difference is due to the introduction of clinical grading in 1988 which, in a single year, increased average real-terms earnings of NHS nurses by 22%.

Further, we undertake international comparisons analysis using OECD data. This gives insights into the variations in the earnings of nurses across a selection of broadly comparable OECD countries, some of which compete with the UK for international nurse recruitment. On average, hospital nurses’ earnings in the UK are lower than the corresponding averages in key comparator economies such as Australia, Canada, New Zealand and the United States. This holds both in absolute terms (when comparing remuneration levels across countries adjusted for cost of living in each country) and relative terms (when comparing the remuneration of nurses to the average wage of all workers in each country).

Additional consideration of the pay determination systems in place in major comparator countries (Australia, Canada, Germany, New Zealand, Sweden and the United States) reveals that most of these countries have a national or regional framework for nurses’ pay determination, underpinned by trade union recognition and collective bargaining. The majority also have options for targeted additional incentives for posts that are particularly difficult to fill. The UK stands out as having long-term reliance on an independent review process as a central element in pay determination for nurses and other professionals working in the public sector.

The effects of COVID-19 on the wellbeing and workload of the nursing workforce in these countries have varied, reflecting differences in the prevalence of the pandemic. However, all the countries have had to scale up the workforce in preparation, and most have experienced very significant increases in surge related workload, stress and reported burnout. All with the exception of England and New Zealand report having made some type of additional COVID-19 related payment to nursing staff.

On the whole, we conclude that over the long term, since it was established in 1983, the pay review body approach has contributed to overall pay determination stability for UK nurses. The ability to reach independent recommendations provides scope to take a considered and evidence-based view of an issue that is always contested and sometimes controversial, and which has significant public funding implications. However the process can only be judged as successful if recommendations are fully implemented by the governments in the four UK countries, which we highlight has not always been the case. In addition, our major qualification to this overall assessment is the negative impact of the 7-year public sector pay cap which ended in 2017. The review body approach also gives scope for planned and agreed changes to be made in the overall pay determination process and structure, and as such it has also been able to underpin several major overall changes in pay structure; however the most recent substantial restructuring was some time ago, with the Agenda for Change reform introduced in 2004.

The broader policy emphasis in the NHS is now on how to ‘build back better’, and part of that broader focus must be to assess if the NHS pay system remains fit for purpose. In its most recent report, the NHSPRB has identified the need for further reform of the system. Along with other key stakeholders, it has highlighted the need for improved pay rates and career pathways for experienced and advanced practice nurses. Further, it has emphasised the need for a more in-depth examination of pay rates and career pathways for experienced and advanced practice nurses, as well as the use of targeted pay supplements, pay equity and the overall reward package. The emerging divergence in the approaches of the four UK countries to NHS staff pay also merits further attention. Accommodating differences within a unified system is leading to tension and it may be time to consider a more devolved pay system across the four UK countries for NHS nurses.

The pandemic has accelerated the need to review the current approach to NHS nurses’ pay determination. The UK government’s recent announcement of a full public sector pay round for 2021/22 is a start. In the longer term, post-pandemic NHS recovery and rebuilding calls for an NHS nurse pay system that is built around supporting workforce sustainability and the achievement of service objectives. However, at the time of writing, the most recent NHS People Plan gives no detailed consideration of NHS staff pay, pay determination processes, and related career structures. Our analysis underscores the need for a comprehensive NHS workforce strategy which places the staff reward package front and centre and acknowledges the centrality of pay as a powerful driver of nurse motivation and retention.

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