Nurses working outside the NHS

About 22% of nurses and midwives work for private companies, charities, local government or other public sector employers, according to the RCN’s 2020 UK labour market survey, which uses data from government, public and independent sector employers, and organisations such as the Nursing and Midwifery Council (NMC).

Many are practice nurses or work in adult social care. The number also includes agency nurses, those employed by social enterprises, community interest companies and private hospitals, and a few self-employed nurses who may offer training or consultancy.

More than 40% of the RCN’s 450,000 members work outside the NHS and the college is currently working on an independent sector pay strategy as part of a wider campaign for fair pay for all nurses.

‘We want our members – wherever they work – to get fair pay, terms and conditions, and our ambition is for those to at least match Agenda for Change,’ says Dolores McCormick, previously RCN independent sector lead and now associate director for Northern Ireland.

Ensuring parity is tricky due to the ‘myriad of employers with a myriad of terms and conditions’ across all four UK nations, says Ms McCormick.

GP practices set pay levels

One problem is a lack of data, says Health Foundation economist Nihar Shembavnekar.

Publicly available data on average earnings in the NHS and social care in England do not show how nurses’ actual pay varies according to gender, experience, roles and geography, he says. ‘There is also very little data on nurses’ pay in primary care and the independent and voluntary sectors.’

GP practices are individual businesses and decide pay, terms and conditions for staff. The GP contract with the NHS does not place any specific obligations on practices concerning pay, terms and conditions for nurses. However, practice nurses are eligible to join the NHS pension.

Some GPs base salaries for nurses on Agenda for Change pay bands, but others choose not to. A report from the Queen’s Nursing Institute in 2016 found many practice nurses were paid well below what they would get in the NHS.

The organisation surveyed more than 3,100 practice nurses in 2020 to find out how they had been affected by the COVID-19 pandemic and found the most frequently mentioned issue was pay and conditions.

‘The discrepancies in working conditions, roles, training, sick pay, pay structure, support, bereavement pay and holiday allowance are really quite shocking,’ said one respondent.

A 2019 review of general practice nursing in Lewisham, London also found widespread dissatisfaction with pay, terms and conditions, and called for standardisation and a recognised pay scale.

Nurse researchers interviewed 50 general practice nurses and advanced nurse practitioners.

NHS South East London Clinical Commissioning Group practice nurse adviser for Lewisham Jane Dolega-Ossowski was a joint author on the review. ‘One practice nurse was being paid the same wage as a healthcare assistant at £13 an hour,’ she says. Others earned £30 per hour, although salaries didn’t necessarily match nurses’ skills and experience.

‘You may have a relatively inexperienced nurse earning £25 an hour, while another who would be a band 7 or 8 at a trust is being paid less,’ says Ms Dolega-Ossowksi.

‘If we want to encourage recruitment and retention of nurses in primary care then this problem needs to be taken seriously at a national level’

Ruth Rankine, pictured, NHS Confederation director of primary care

Lack of occupational sick and maternity pay were common complaints among interviewees.

Advantages outside the NHS

One advantage of working in general practice is the ability to negotiate better pay – although that relies on nurses having the necessary skills and confidence, says Ms Dolega-Ossowski.

Other benefits include the hours. ‘You’re more likely to be working nine to five than in a hospital where you’re expected to do 12-hour shifts,’ she says.

There is huge variation in pay, terms and conditions in adult social care, where most nurses work for independent sector providers, with a few directly employed by local authorities.

According to the Skills for Care latest annual workforce report, the majority work in residential care settings with some in domiciliary, community or day care. The number of nursing jobs across this sector has fallen steeply in recent years, with many residential settings becoming care homes without a registered nurse presence due to chronic nurse shortages.

Nurses can pick and choose where they work, and turnover is very high, at 41.3%, compared with 9.4% among NHS counterparts.

Taking the stress out of pay negotiations

Susan Phillips, lead research nurse for primary care for the South London Clinical Research Network, has moved between roles in the NHS and general practice nursing.

She has generally been happy with her pay, terms and conditions, but had to fight to get the salary and terms she deserved.

Following a stint in intensive care, she trained to be a children’s nurse and after starting a family in 1990 she decided to move into primary care, in part because she could fit childcare arrangements around her work.

‘They tried to move me back down the pay grades’

The move involved a pay rise but she had to push to get it. ‘The doctor tried to put me back down the pay grades, but I stood my ground.’

She worked for several practices across Lewisham and was employed for 12 years at a large group practice in Sydenham. ‘I asked for the top of band 6 and they gave it to me because of my experience,’ she says.

However, when she moved back into the NHS to work in smoking cessation she was shocked to discover that her many years of experience essentially delivering NHS services was not recognised. ‘They tried to put me back to the bottom of band 6. We came to a compromise in the end where I was middle-banded and got more holiday, but negotiating was stressful.’

Ms Phillips says GPs she worked for generally used Agenda for Change as a guide when working out her salary. However, she says she has been lucky and would like to see greater standardisation. ‘You could be working for a good GP that thinks about their staff or a terrible one that doesn’t really care,’ she says.

As demand has risen, so has pay

Meanwhile, pay has shot up. Average annual salaries for those working for independent providers increased from £23,000 in 2011-12 to £31,800 in 2019-20 – a 38% rise – according to data from Skills for Care.

In comparison, NHS Digital data show the average annual earnings for health visitors and nurses in the NHS in England was £34,310 in 2020.

Some employers offer better pay and conditions than the NHS, says Martin Green, chief executive of Care England, which represents independent social care providers.

Employment packages might also include a welcome bonus. ‘I’ve seen people offered cars, private medical insurance, increased holiday pay or longer holidays,’ says Mr Green.

But not all hard-pressed providers can afford to be so generous and he admits it is hard to compete with the NHS pension and its investment in training.

However, the sector has other things to offer. ‘Nurses I’ve talked to say they feel more valued, can work directly with service users and see real improvements,’ says Mr Green.

Many nursing homes are effectively nurse-led units. ‘So they do have that higher status and more autonomy,’ he adds.

The charity sector also struggles to compete with the terms and conditions for nurses in the NHS or higher education. However, nurses say they value the freedom to innovate.

A ‘candidate-led market’

The fact there are simply not enough nurses to go around in the social care sector means it can be a ‘candidate-led market’, says Steve O’Brien, founder and chief executive of Outt – a recruitment agency that pairs employers with nurses seeking temporary shifts mainly in nursing and care homes.

Mr O’Brien says that, in real terms, wages have increased in recent years. On average, a shift with a large care provider pays about £20 per hour with holiday pay on top and up to £6 an hour extra for unsocial hours.

Nurses are attracted by the flexibility and those working full-time can earn as much as £50,000 a year, he says. ‘They can pick and choose shifts, dip in and out of rotas and work in services they like.’

New legislation to prevent tax evasion means people classed as ‘off-payroll workers’, such as most agency nurses, can no longer claim expenses against tax and must cover their own travel costs. Other downsides are the potential last-minute cancellation of shifts and the level of responsibility that is sometimes required.

‘It takes a certain kind of nurse. You rock up at a nursing home for the first time, get a whistle-stop tour and are thrown the drug keys as the day nurse runs out the door,’ says Mr O’Brien.

‘You may be the only nurse or most senior person on duty, so ultimately it’s a leadership role.’

Pay, terms and conditions for general practice nurses are decided by individual GP practices

Picture credit: iStock

Barriers to standardisation

A key challenge in standardising pay, terms and conditions for non-NHS nurses is the lack of collective bargaining power, explains the RCN’s Ms McCormick.

The RCN does have recognition agreements – frameworks to establish positive relationships between a union and employer – with some independent sector employers.

But the RCN’s focus is on developing an organising model to support nurses on the ground to negotiate better pay, terms and conditions themselves.

Many nurses outside the health service deliver services funded by the public purse through the NHS or local authorities, says Ms McCormick. ‘Those commissioning or purchasing care need to give attention to the terms and conditions of workers.’

There is currently a mismatch in funding for community services commissioned by local councils, explains Andrew Ridley, chair of the Community Network hosted by NHS Confederation and NHS Employers.

‘This is a significant issue for all community providers including non-NHS providers of community health services such as social enterprises and community interest companies,’ he says.

Any moves to standardise pay, terms and conditions for general practice nurses will also require adequate funding, adds NHS Confederation director of primary care Ruth Rankine.

‘If we want to encourage recruitment and retention of nurses in primary care then this problem needs to be taken seriously at a national level and, of course, any pay uplift must be fully funded,’ she says.

However, it’s important to remember standardisation may not suit nurses who have successfully negotiated favourable pay, terms and conditions, says Queen’s Nursing Institute (QNI) chief executive Crystal Oldman: ‘Some care home nurses might say “Don’t come near me – I’ve got a really good deal here”.’

Dr Oldman says a symposium for GPs and nurses hosted by the QNI in March 2021 shows doctors understand the issues surrounding pay and are keen to find solutions.

What about negative effects?

Adult social care providers may fear additional requirements around pay, terms and conditions could decimate an already struggling sector.

‘It’s not only about pay and conditions,’ adds Care England’s Mr Green. ‘What we need is a proper workforce strategy to mirror the NHS workforce strategy, with a clear skills and competencies framework and career pathways.’

In January this year, NHS England, NHS Improvement and the British Medical Association’s GP Committee set out measures to support general practice in 2021-22, including a commitment to review and agree terms and conditions for practice staff ‘within existing resources’.

As part of that, the bodies will undertake a survey to gather accurate information on current terms and conditions to inform good practice guidance.

What is bank nursing and how might it work for you? rcni.com/bank-nursing