The current NHS pay deal means nurse salaries in England are finally keeping up with the rising cost of living after years of stagnation following the financial crash, according to early analysis published in a report this week.
“Some of that value has been recovered as a result of the AfC pay agreement”
NHS Pay Review Body
However, mounting workplace pressures driven by staff shortages and escalating demand poses a risk to nurse retention and also patient safety, warned the latest annual report from the NHS Pay Review Body.
The body found that the value of starting nurse pay had fallen between 2009 and 2017, but the three-year Agenda for Change (AfC) deal implemented last year had “recovered” some of that loss.
However, it said it was too early to know the true effect of the deal, because the “most significant” changes around pay band structures would take time to embed.
“For nurses, we note that starting pay has lost value between 2009 and 2017, particularly compared with RPI inflation, and to a slightly lesser extent relative to full time employee earnings growth,” said the report. “Some of that value has been recovered as a result of the AfC pay agreement in 2018-19.”
The report said the increase in value of the starting pay point for nurses contained in the AfC pay agreement for 2018 was greater than the recorded increase in inflation, and to a lesser extent, average earnings.
“The lack of further progression opportunities could be demotivating”
NHS Pay Review Body
The agreement saw pay bands shortened so staff could get to the top quicker, meaning pay increases would less frequent but larger.
The report shows that at April 2018, more than 40% of Agenda for Change nurses were at the top of their pay band.
Concern was raised that this change could lead to more staff spending a longer part of their career at the top of their pay band.
“The lack of further progression opportunities could be demotivating, put pressure on the grading system and could influence retention,” the report said.
It suggested that “career development incentives” might be needed to address this issue and keep staff driven. The pay body said it would continue to assess this as the agreement was implemented.
Taking a longer-term approach to reviewing pay looking at the entirety of an individual’s NHS career would become an “increasingly important” of the pay evidence base, said the review body’s report.
Data included in the report found that nurse pay was ahead of the median earnings of graduates for five years after qualifying but fell below the average after 10 years.
“The workforce gap we recognised in our last report persists”
NHS Pay Review Body
However, the report added: “This position could change with other developments in the labour market and pay settlements elsewhere, and in the light of increased AfC starting pay, faster pay progression through the AfC pay bands and the potential for pay to flatten out as staff reach the top of pay bands.”
The role of the NHS Pay Review Body is to provide independent advice to leaders in the four countries in the UK on NHS staff pay.
This year the body was not asked to make any recommendations on pay because the Agenda for Change deal has already been agreed until 2020-21.
Instead, the body used its annual report to give some early feedback on the implementation of the deal and provide wider observations on issues affecting the Agenda for Change workforce.
The report noted that the workforce challenges were the “most significant” facing the NHS and could put patient care at risk.
“The workforce gap we recognised in our last report persists and continues to create unsustainably high levels of vacancies, work pressures and potential risks to patient care,” said the report.
The trends in the nursing workforce were a “particular concern”, said the document, highlighting the increasing vacancy rate and decline in nursing degree applicants seen in the past two years.
Even with the use of bank and agency staff, there was still a gap of more than 8,000 registered nursing staff in England.
“Shortages affect the workload of staff since the NHS relies on their goodwill and their willingness to do paid and unpaid overtime,” noted the report.
“These issues could impact on staff motivation and morale, their retention, their willingness to recommend the NHS as a career, and on services to patients.”
The report highlighted how there had been a 26% fall in the number of nursing applicants since 2016 and a “small decrease” in acceptances to nursing degrees.
However, there were still more people applying to study nursing then there were places and this was understood to be in part due to a shortage of clinical placements.
To address this, the government has agreed to provide funding for an extra 5,000 clinical placements for nursing.
The report said this could in theory lead to a “significant rise” in the number of people studying nursing in 2020, 2021 and 2022.
But it questioned whether this would be possible without action to make nursing more appealing to students, given the drop in interest in the profession since the bursary was scrapped.
“It is important that clear mechanisms need to be in place to improve the attractiveness of nursing within the NHS and to encourage the right numbers of suitably qualified applicants,” said the report.
“There needs to be further evidence on the way in which the targets can be achieved given the current trends and a better understanding of the factors driving applicants, acceptances and attrition.”
It noted how the bursary remained in place in all countries except England and there were increases between 2016 and 2018 in applicants accepted to study nursing in Scotland and Wales.
The report pinned hopes on the upcoming NHS People Plan – also known as the Workforce Implementation Plan – to set out the required staffing redesign needed to support the vision of the NHS Long Term Plan published in January.
The effectiveness of the new nursing associate role would be a “key leading indicator in assessing the success of workforce developments”, said the document.
It added: “The new roles represent a small part of the solution to closing the workforce gap and a strategic approach to deployment will be required to realise the ambitions of the programme.
“There is a need for overarching direction, leadership and a coherent strategy across the NHS in order for the role to be deployed effectively.”
The body also called for more clarity over the role to be played in the long term by NHS bank staff, noting how the health service relied on a “consistent source” of temporary staff to meet demand.
In addition, it appeared to echo concerns raised by the Royal College of Nursing around safe staffing accountability.
“The accountability for workforce planning continues to be dispersed across a number of bodies despite the need for system-wide solutions,” it said.
In terms of the implementation of the deal to date, the body appeared to point to the row that broke out last summer between the RCN and members who claimed the college had misrepresented to offer to them. The fall-out led to former RCN chief executive Janet Davies resigning.
“We heard on our visits late in 2018 that there were difficulties in the initial communications on the impact of the AfC agreement given the complex variations for individual AfC staff,” it said.
“We also heard about the efforts of individual trades unions at national and local level in helping AfC staff understand the pay reforms.
“We continue to stress the importance of extensive and regular communications to AfC staff and trust management during the implementation of pay reforms given the complexity of structural change ahead in Years 2 and 3, and the resulting individual pay journeys.”
Meanwhile, the body also recognised concerns raised by the Royal College of Midwives over the “inappropriate” banding of maternity support workers at band 2, which is now the lowest band in the Agenda for Change structure following the removal of band 1.
The RCM told the review team that maternity support workers carried out delegated clinical tasks which did not match the band 2 job profile and that if the NHS Job Evaluation Scheme was applied correctly than these duties would attract a “much higher level of renumeration”.
The college also noted how a “significant reduction” in band 7 posts was making midwifery a less attractive career.
Overall, the body said it was too early to make a judgement over the effect of the latest Agenda for Change pay deal.
“There are a limited number of implementation issues to review at this stage and it is too early to make an assessment of the long term impact of the AfC pay agreement,” it said.
“Many of the major impacts, such as changes to pay structures and progression arrangements, will take time to embed and influence recruitment, retention and motivation, and will be assessed in our later reports.”
However, it did highlight that the 2018 NHS Staff Survey in England indicated that levels of satisfaction with pay had increased over the previous year.
Dame Donna Kinnair
Reacting to the report, Dame Donna Kinnair, chief executive and general secretary of the RCN, said: “In this report, neutral advisors are putting on record their concerns about mounting pressure in the NHS workforce. It should be top reading for any new ministers this week.
“A report for government has now put it in black and white that the ‘unsustainably high’ number of unfilled jobs puts patient care at risk and that, in England, the removal of the bursary sent things into ‘decline’. They sadly conclude that the lack of accountability for resolving this crisis is adding to the problem.
“The report notes yet again the fact that the NHS relies on the willingness of staff to do unpaid overtime and that should never be the case. The evidence they present here must mark a moment on the way to a meaningful future pay rise.”
Dame Donna said it was now “hard to see” how anyone could disagree with the RCN’s call for reinvestment in nursing education and new safe staffing legislation in England.
Jon Skewes, executive director for external relations at the RCM, said the document had highlighted some “important issues”
“The report rightly points out that staff satisfaction with pay has increased but we need to ensure that this increased satisfaction is maintained, indeed improves, and this will rely on ensuring fair pay deals in the future,” he said.
“The improvement shows that the three year pay settlement is a good start but we need to continue this work of valuing NHS staff.
“The NHS Pay Review Body stress the continuing pressure on staff due to excessive workloads and the ability of this to undermine staff morale. There are still many midwives working often unpaid overtime and showing extreme goodwill to ensure services remain safe and of high quality.”
He said he was “very pleased” that the report had noted the college’s concerns about maternity support worker banding and pay.
“There is clearly a need to ensure that these very important members of the maternity team are fairly rewarded for the work they do,” he added.
Danny Mortimer, chief executive of NHS Employers, welcomed the report and its recognition of the workforce challenges facing the NHS.
He said: “Although there are no recommendations because of the current multi-year award, the report rightly highlights the workforce challenge faced by the NHS and the impact on recruitment, retention, morale and well-being.
“We look forward to working with our partners and stakeholders to realise the ambitions of the NHS People Plan to grow and support the workforce and make the NHS the best place to work.”
Health and social care secretary Matt Hancock said he was pleased the pay body’s observations “broadly reflect” the themes in the interim NHS People Plan and said they would help inform the upcoming final version.