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Nurses on NHS contracts have a new pay offer, but staff working outside the NHS are not part of the dispute and pay and conditions vary widely
Pay talks between the government and health unions in England have reached a crucial juncture with a new offer for nurses and other healthcare staff on Agenda for Change (AfC) contracts.
Primary Health Care. 33, 3, 6-8. doi: 10.7748/phc.33.3.6.s2
Published: 30 May 2023
But what does this development mean for the nearly one in four nurses who work outside the core health service contract – if anything?
An estimated 22% of registered nurses and midwives work for private companies, charities, local government or other public sector employers, according to the RCN’s most recent UK labour market survey in 2020, which used Office for National Statistics data.
The pay dispute involves nurses and other staff who are on the AfC contract, which covers those working for all types of NHS trusts, providing services ranging from hospitals and mental health to community care.
Nurses working for ambulance services and national organisations such as NHS England and NHS Blood and Transplant are also on AfC. The situation is similar in other parts of the UK, which all have the contract in place. But general practice nurses (GPNs) are not on the contract, except where a general practice is run by an NHS trust.
Other nurses not on the standard NHS contract include those working in social care and education, as well as nurses employed by charities and private companies in fields such as mental health, learning disability services, hospice care and the criminal justice system.
RCN transformation lead for independent health and social care Claire Sutton says there is a huge variety of roles. ‘Nurses are everywhere – supermarkets will even employ them in occupational health roles. Around 40% of our members are nurses who are not on AfC.’
Ms Sutton says this means there is a wide disparity in earnings. ‘There are some nurses in independent and social care sectors who are paid higher basic salaries than those in the NHS.’
But she says what is often inferior are benefits such as sick pay, maternity pay and pensions.
» Talk to colleagues about the rising cost of living and list some items that have gone up in price. Gather this information and use it as evidence to present to your employer
» Think about your workplace Do you have high turnover of staff? What are the sickness levels like?
» Create a survey among colleagues, which you can use as evidence to seek a pay rise or other improvements to your terms and conditions
» Find out about the real living wage and whether your employer is meeting it
» Find out if there are any RCN reps at your workplace and seek support from them, or contact your local office
» Do your research On the RCN website, ‘Pay, terms and conditions in independent employers’ and ‘Our fight for fair pay in non-NHS settings’ will help you learn more about how other workplaces have organised for better pay
» Approach your employer once you have agreed the issues with colleagues and spoken to your RCN rep. Writing as a group of staff will have the biggest impact
» Use a template letter such as this one from the RCN – tinyurl.com/rcn-template-letter – to set out your case and provide evidence to your employer
Many of the non-NHS fields are mixed markets, where nurses work for a variety of employers including the private and voluntary sectors and local government.
This includes services that would usually be seen as within the NHS family, such as learning disabilities and mental health, as well as support for end of life care and cancer, which is sometimes provided by charities such as Macmillan Cancer Support and Marie Curie.
Then there are public sector services such as prisons, the wider criminal justice system and public health.
Public health nurses such as school nurses, health visitors and sexual health nurses work for services that are commissioned by councils. Some will be employed directly by councils but others will be working for voluntary and private-sector employers. But in all these sectors there are cases where NHS trusts have the contract to provide the service, and when this is the case the nurses will be on the AfC contract.
School and Public Health Nurses Association chief executive Sharon White says this creates anomalies in pay, as well as terms and conditions, with those not employed by the NHS often earning less than their AfC peers.
‘For non-NHS providers there is a potential crisis if and when a pay rise is agreed, as they won’t be getting any extra funds from commissioners to offer the same uplift, either leaving them well out of pocket or unable to match the pay rise,’ says Ms White. ‘It seems very hard at the minute.’
The sector that perhaps most closely mirrors AfC is general practice nursing. There are 23,000 GPNs in England, and more than 30,000 across the UK nations as a whole.
Nurses working in this field are part of the NHS pension scheme but are not on the NHS contract. National recommendations about pay rises are made by NHS England, but GP practices do not have to follow them.
‘Some will pass it on and some will not,’ says RCN general practice nursing forum chair Ellen Nicholson. ‘It means there’s a lot of variety in terms of pay.’
She says AfC banding is used by some practices as a loose framework to reward seniority. But at other practices, nurses find themselves stuck at relatively low rates of pay for their responsibilities.
‘Some GP nurses find themselves trapped at what is effectively a band 5 level, despite skills and experience far beyond this level.’ This leads to a high turnover in jobs in certain areas, says Ms Nicholson.
Sarah Hall, who is also on the general practice nursing forum, says practice nurses were confused when they were not part of the original RCN ballot for industrial action on pay. ‘They think of themselves as being part of the NHS. It reinforced that feeling of being marginalised.’
‘For non-NHS providers there is a potential crisis if and when a pay rise is agreed, as they won’t be getting any extra funds from commissioners to offer the same uplift’
Sharon White, chief executive of the School and Public Health Nurses Association
She says most GPNs would like to be on AfC, with the exception of some senior GPNs and advanced nurse practitioners who have been able to negotiate higher levels of pay for themselves.
‘This is the difficulty for nurses in general practice – it comes down to how good you are at asking for pay rises.’
The area of practice with the greatest number of non-NHS nurses is social care. In England there are 32,000 nurses employed in the sector, with the number approaching 50,000 once the other UK nations are included.
Most of these nurses work in care homes and nursing homes. Their average pay in 2020-21 in England was more than £35,000, according to Skills for Care, which is slightly higher than in the NHS average. But vacancy and job turnover rates are higher.
National Care Forum board member Anita Astle, who is a registered nurse, says social care nursing comes with huge responsibilities and pressures, given that these staff are in charge of caring for people with frailties and clinical needs without the access to doctors that most NHS nurses have.
But she says that while pay may be better for some, benefits and pensions are mostly inferior to those available to NHS nurses, and access to training can be more difficult.
She says this can be frustrating for social care nurses, but those in this sector generally would not consider taking industrial action. ‘They don’t go on strike. Often there are only one or two nurses in a care home and they know the residents well. They’re like family, so there’s a reluctance to take industrial action.
‘Plenty are members of either Unison or the RCN, but it’s more for professional indemnity reasons. A pay rise in the NHS will put pressure on social care – nurses will point to it in pay discussions – but money is so tight. It is difficult.’
Jan Gower has spent more than 20 years working in general practice nursing, becoming an advanced nurse practitioner as well as GP nurse trainer. It has been a fantastic field to work in, she says, but working outside of the Agenda for Change (AfC) contract comes with challenges.
‘It’s a two-tier system’
‘I’m lucky I worked in a good practice that supported its nurses and tried to pay us fairly. But not all nurses in general practice have that.
‘We benefit from being in the NHS pension scheme, but you have to be careful. I spent five years in education, but made sure I kept doing some work in general practice so I made the contributions I needed.
‘It’s always had a two-tier system, but if we see a pay rise of, say, 5% agreed for AfC I fear it will make it harder to recruit to GP nursing. We would never get an uplift like that.’
Nicky Hewitt left an AfC role in a district nursing team two and a half years ago, and is now a lead GP nurse in Dorset.
‘There are some significant differences, so you need to be aware of what you are entitled to,’ she says. ‘You also have to be prepared to be engaged with pay. On AfC there is transparency – you know what you are paid, how that is going to increase and that you will get the pay rise that is agreed nationally.
‘But in general practice that is not a given. Recommendations are made but it is up to individual practices whether they follow that. Some do, some don’t.
‘Some nurses have to fight for their pay’
‘There is a lot of variety in terms of overall pay. You can find practice nurses on one side of a town are on much better pay than those on the other. Where I work it is organised on a primary care network level, which keeps loosely to the AfC pay scales – a newly qualified nurses is on something similar to band 5 rising to band 6 for more senior nurses and broadly band 7 for lead nurses.
‘It works well, but not every GP nurse is so lucky. Some have to fight for their pay.’
In the education sector, the RCN is not recognised as a trade union for pay negotiations, leaving nurses working for universities and other education providers having to take out membership with an education union.
Those working as university lecturers are involved in their own dispute, involving pay and pensions. Strikes were paused in February after employers and unions – including the University and College Union, Unison and the GMB – resumed talks.
RCN education forum chair Sarah Burden says things are difficult in the sector at the moment.
‘Pay and conditions have been eroded over the past ten years. This does cause a problem recruiting nurses into academic roles, as ironically the pay scales – particularly for advanced practitioner lecturers – can actually be less favourable than AfC.’
Some nurses working for universities will also be involved with research, but this area is a mixed market, with research nurses employed by NHS trusts and the pharmaceutical industry, creating significant variations in pay and conditions as it does for nurses in fields such as public health.
Ms Sutton believes that while any agreement on AfC will not directly benefit non-NHS nurses, it could still have a positive influence. ‘We are hearing that the industrial action has galvanised nurses in other sectors to start talking to their employers about pay. It is difficult in areas where there are only a few nurses. There are things you can do though, including coming together with others locally to bargain as a group.
‘The RCN and our network is here to support. The RCN is recognised by a number of employers, but the challenge we face in the independent and social care sectors is that there are thousands. It would be impossible to negotiate with all employers individually. But remember that local reps are available to advise and support nurses with their pay claims.’