Route out of the bottom of the AfC pay bands is unclear

Former RCN general secretary Pat Cullen, who stepped down from the role in May to stand as a candidate in the UK general election, said in an earlier statement that AfC, introduced two decades ago, has lost sight’ of nurses’ value. ‘After 20 years, three quarters of our members are on the two lowest pay bands possible for registered nurse professionals,’ she said. ‘We are weighted to the bottom of the pay and grading structure, without a clear route.’

Under a new separate system, specific qualifications would bring fixed financial rewards, says the RCN, and international nurses would have their experience recognised, rather than automatically starting at the bottom of band 5.

Unions, health policy experts and nurses themselves are divided over whether discarding the existing AfC contract and creating a nurses-only pay scale will be any more beneficial than tweaking the current system.

AfC promised fairer pay across occupational groups in the NHS

GMB union national NHS advisory group chair Martin Jackson, a coronary care unit charge nurse at Barnsley Hospitals NHS Foundation Trust who has been nursing for 20 years, says that when AfC succeeded the complex Whitley system in 2004, it worked.

‘AfC promised a fairer single salary system for all NHS staff, apart from doctors, dentists, and senior managers,’ he says.

But as the cost of living has surged and nurse pay has fallen in real terms, staff have become more discontent, he says. Yet, he believes, a new nursing pay structure is not the answer.

‘The AfC pay awards for the last 14 years have been minimal,’ he says. ‘But I can’t see how that would change with a new nurse pay structure or contract.

‘I don’t think nurses in general are in favour of anything that separates them from other NHS staff. Other professions, like midwives and paramedics, progress from band 5 to 6 in two years. So, AfC works if used properly.’

The case against the profession having its own NHS pay spine

The idea of nurses having their own pay system has split health unions. GMB, Unison, Unite and others are all against it.

NHS Employers, which acts on behalf of NHS trusts in England and Wales, is also opposed to a separate pay spine for nurses, arguing in its evidence to government that it would affect morale and patient care by moving away from a multidisciplinary approach to service delivery.

AfC pay bands have always been decided according to the job evaluation scheme, which judges roles against 16 factors, such as knowledge, analytical skills, responsibility and physical skills. The job is then scored and matched to a pay grade.

Picture credit: John Houlihan

Anyone can request a review of their job’s banding if they think it is wrong, with agreement from their line manager.

In reality, moving up the banding is not straightforward, says Mr Jackson, who is GMB lead for job evaluation.

‘The number of nurses in the NHS is huge compared to other professions,’ he says. ‘It’s far more expensive to pay for most nurses to be band 6 – even if many are working to band 6 level – compared with most midwives being band 6. That’s why the government won’t do it. A separate nurses’ pay scale won’t overcome the problem of nurse numbers.’

The national job evaluation group, of which he is a member, is currently reviewing nursing profiles, he says.

‘After 20 years of AfC, three quarters of RCN members are on the two lowest pay bands possible for registered nurse professionals...weighted to the bottom of the pay and grading structure, without a clear route’

Pat Cullen, pictured right, former RCN general secretary

‘Job evaluation profiles for nurses have remained the same for 20 years of AfC,’ he says. ‘But even if the role descriptions change, the problem you’re stuck with is that employers will only pay for a limited number of nurses paid at band 6 salaries, whatever the pay structure.’

Scotland’s nurses paid more than those elsewhere in the UK

The UK government determines pay for NHS staff on AfC contracts through consultation with the NHS Pay Review Body (RB). The RB was set up to advise on pay awards as an independent public body, but the RCN has cast doubt on whether it is truly independent from government.

Salary reviews in England, Wales and Northern Ireland all go through the RB, but NHS Scotland’s AfC pay is agreed through direct negotiations between health unions and the Scottish Government.

Senior fellow at the Health Foundation think tank James Buchan, who has a background in health workforce policy analysis, says: ‘The most prominent change regarding AfC was when the Scottish Government withdrew from the review body system and moved towards direct negotiation at Scotland level with the trade unions.

‘The most obvious outcome has been that Scottish nurses are paid more than nurses in other UK countries. Direct negotiations meant the AfC process could be retained, but the pricing of it moved up in Scotland compared to other UK countries.’

The rising cost of living has been yet another challenge for nurses

Picture credit: iStock

Separately, in 2018 a three-year pay deal was agreed for England. This meant that starting salaries increased across pay bands, the top of pay bands rose, and overlapping pay points were removed.

Whether AfC works to the benefit of nurses is, in part, about whether the mechanisms it uses, such as the RB, are fit for purpose.

‘It’s worth considering whether the RB has continued to be an effective way of identifying pay for nurses and other NHS staff,’ says Professor Buchan, who has also worked with the World Health Organization and the World Bank.

Nurses in Scotland’s NHS are paid more than their counterparts elsewhere

Picture credit: iStock

The case for direct negotiation as an alternative model

‘There were several years of what amounted to a pay freeze, and the annual pay review process has often been delayed and not delivered what nurses hoped. The fact that the Scottish Government moved away from the process highlights an alternative model, which is direct negotiation.’

Nurses in Scotland have remained on an AfC contract, but withdrawing from the RB has brought benefits without moving to a separate nurse pay system or contract.

‘Scottish nurses now have a relatively high level of pay compared to others, but also a reduction in working hours without pay reduction, which is another hidden pay increase,’ says Professor Buchan.

Improved pay and conditions key to promoting retention

Nuffield Trust senior fellow in health policy Billy Palmer says there are problems with AfC, but they are about pay progression rather than the pay structure itself.

‘Changing contracts or developing something from scratch, that’s always tough,’ he says. ‘It’s expensive, it takes time, and doesn’t always deliver the benefits wanted. Implementation might be difficult.

‘So, you have your registered nurses working in another NHS role – for example a mental health nurse as a cognitive behavioural therapist. Currently, both those jobs are on AfC, but if nurses are on another contract, how does a nurse working as a therapist work out?

‘There are ways of making AfC more rewarding. Data suggests that when people are in the NHS for five years, they tend to stay. So, as an example, it could be that after five years, some student debt is wiped off for nurses.’

The future of AfC must involve improved pay and conditions if retention of NHS nurses is to improve, he says.

‘A new system could end up being another set of reasons for nurses to feel aggrieved. Whatever the contract or pay spine, the need to be bold about pay and conditions will be the main thing affecting nurses. It’s difficult to say whether something new will make that easier to achieve.’

Nursing Standard podcast: Why are nurses’ pay and conditions better in Scotland? rcni.com/podcast-scotland-pay

Look ahead to what to expect in the 2024-25 AfC pay round rcni.com/next-AfC-pay-deals