It outlines our evidence on key areas including employers' views on affordability, the financial position of the NHS and staff satisfaction. For more details, see the full report.
General
The purpose of the reward package in the NHS, as for any employer, is to ensure the recruitment and retention of the appropriate numbers of staff, the appropriate skill and knowledge mix among the staff, and the correct quality of application of that skill and knowledge at the correct place and time, to provide the services required.
Reward, of course, is not only about pay rates. It is also about tangible and non-tangible non-pay rewards. It encompasses pensions - deferred wages, conditions of service and how staff are managed. It is about the total reward. In effect, this evidence is about what people do, what they are paid and how they are managed.
The Department of Health has published research as part of the Next Stage Review, looking at what affects staff in the NHS. Based on surveys and group discussions, the research identified factors that matter to staff. Crucial among these were involvement, including being treated with trust, being listened to, understanding the big picture and working together. In effect, what matters to staff is having a worthwhile, supported, resourced job with opportunities.
The findings of the NHS Staff Survey, conducted by the Healthcare Commission in relation to staff satisfaction, are addressed elsewhere in this submission.
While economic conditions have effects on the labour market and on affordability, the primary drive of any recommendations of the Review Body need to reflect the primary drive of any reward strategy in the NHS - that is, to recruit, retain and motivate the appropriate numbers, skill mix and quality of medical and dental staff.
In comparison to other professional jobs in the economy, doctors and dentists are in an occupation on which prevailing economic circumstances have a limited effect because the employment and contracting of doctors and dentists is largely within the NHS in the UK, with only 3 per cent receiving their primary income from other sources, such as those in academic work. Competition with the wider labour market and the wider economic circumstances are not thought to be the primary factors in the recruitment and retention of doctors and dentists.
NHS employers recognise that the definitive sources of evidence on the economic context and affordability are HM Treasury and the health departments. In advance of the Primary Care Trust (PCT) allocations being announced for 2009/10 and the NHS tariff being published, employers will have to take a view on the affordability of their workforce. A key national guidance paper supporting local operational and financial planning for 2009/10 and beyond is expected to be published by the Department of Health (DH) during the autumn of 2008 and will include:
- Details of a new formula for the allocation of resources to PCTs
- Individual PCT allocations for 2009/10 onwards
- The level of uplift being applied to the national tariff for 2009/10
- Clarification of key deliverables for 2009/10 and beyond
Whilst awaiting publication of that guidance, local financial planning has been based on best available data and estimates. These have also been used to underpin the analysis in our review of NHS cost pressures and financial planning in 2009/10 to 2010/11 (see full evidence document).
The headline revenue settlement announced for 2009/10 in the Comprehensive Spending Review for the 2008/09 to 2010/11 was 6.7 per cent per cent growth. Organisations are expected to deliver 3 per cent in cash releasing efficiency savings which equates to an effective increase of less than 4 per cent.
The financial position of the NHS, together with the current financial positions of NHS trusts, helps form a view on affordability for the sector. Last year, NHS Employers looked at the cost drivers and financial planning assumptions across individual NHS organisations from 2007/08 to 2010/11 for inclusion in their evidence to the review bodies in 2008/09. A similar investigation has been undertaken this year to:
- Determine whether the costs or financial planning assumptions have changed since then and,
- analyse the latest financial planning assumptions and financial forecasts being made for 2009/10 and 2010/11.
It is important to consider the impact of both current and future inflation levels on affordability of any recommendation. Fuel price increases in particular are imposing unexpected costs on NHS organisations both in terms of running their businesses and in relation to the delivery of goods and services to them. This also led to significant increases to car allowances paid to staff for the first time in seven years.
According to the Office for National Statistics, the Consumer Price Index (CPI), the Government's target measure of inflation was 4.7 per cent in August, up from 4.3 per cent in July. The main upward pressure came from housing and household services due to a rise in average gas and electricity bills this year, compared with the fall last year. There was a large downward effect from the price of heating oil which fell by more than last year, following a reduction in the price of crude oil. Further large upward pressures came from food and non-alcoholic beverages. There was a large downward pressure from transport costs, mainly due to the price of fuels and lubricants. The future of oil prices over the coming year remains uncertain and since the main upward pressures are from food and non-alcoholic beverages, there are risks associated with food and oil that may increase costs for NHS organisations and put pressure on budgets and hence affordability.
The final accounts for the end of year 2007/08 (Quarter 1 2008/09 NHS Finance, Performance and Operations, Department of Health) show that the NHS delivered an overall surplus of £1,667 million with NHS organisations planning to maintain a contingency at this level for 2008/09 and beyond. Financial returns for the first quarter of 2008/09[1] show that the NHS (excluding foundation trusts) is forecast to deliver an overall surplus of £1.75 billion. As a proportion, this represents just over 2 per cent of total NHS resources. All of the surplus sits with NHS organisations and is intended to provide stability and flexibility to deliver plans for service development, sustainability and enhancement over the next decade, which have been set out by staff and clinicians involved in the Next Stage Review.
Monitor, the independent regulator of foundation trusts, reported on the finances of the 89 authorised foundation trusts to 31 March 2008. It reported a combined net surplus over the twelve month period of £514 million.
The surpluses are non-recurrent and have generally been achieved through short-term measures which will not generate such savings year-on-year. Examples include the postponement of essential investment through temporary delays to patient care initiatives. Such measures cannot be repeated each year due to the longer-term and permanent impact they would have upon patient care and activity/waiting list targets.
Existing non-recurrent savings are not therefore available for investment in recurrent areas of expenditure, such as staff pay. To do so would generate un-funded recurrent commitments for future years thus returning the NHS to the boom and bust cycle which has contributed to the significant historic deficits seen over recent years.
The financial position and financial management of the NHS continues to improve though and further repayments of historic deficits and strengthening of individual organisations' balance sheets should be expected. This remains dependent upon continued robust management of financial plans and overall control of recurrent commitments. The number of organisations facing a deficit at the end of 2007/08 was five and the overall deficit was £125 million.
The 2008/09 analysis, contained within the 2008/09 review body evidence of NHS Employers, was broadly in-line with the current expenditure baselines for all NHS organisations, indicating the robustness of the assumptions and forecasting of organisations.
In summary there were three main factors impacting upon the previous financial planning assumptions being made by most NHS organisations:
- Higher than anticipated financial allocations for 2008/09
- Additional national commitments linked to Lord Darzi's Next Stage Review
- An increase in efficiency targets from 2.5% to 3.0%
PCTs previous planning assumptions were for an increase in their centrally allocated revenue resource limits of 3.5% for 2008/09 onwards. The Comprehensive Spending Review proposed an increase in NHS spending by an average of 4% above inflation each year through to 2010/2011. The specific one year allocation announcement for 2008/09 increased PCT allocations in England from £70.35 billion in 2007/08 to £74.20 billion, an actual increase of 5.46%.
The Comprehensive Spending Review announcement included confirmation that the minimum expected annual efficiency saving was being increased from 2.5% to 3.0% alongside the expectation of further value for money reforms realising annual net cash-releasing efficiency savings of at least £8.2 billion by 2010/2011.
NHS organisations contributing to the review of cost drivers and financial planning all stated that the ability to continue to deliver year-on-year marginal efficiency is now significantly diminished and organisations are having to focus on more 'process improvement' to deliver future efficiency savings. Such process improvement, it was stated, generally needs up-front investment to deliver medium to longer-term savings.
Money within the NHS budget is not specifically allocated to spend on annual pay increases. The pay bill at PCT level is met from the overall allocation of funding for PCTs. Resources for trusts come to them via the PbR tariff. As pay is by far the greatest element of expenditure across the NHS, typically 65-70 per cent of expenditure within provider trusts, cost pressures against these budgets forms a significant risk to the employing organisation.
Careful consideration must be given to the impact on services of any pay increase not reflected in PCT allocations or tariff. Employers stress that affordability is dependant on an appropriate increase in the tariff for 2009/10 given the confirmed spending plans over the 2008/9 and 2009/10.
The work commissioned on cost pressures on the service indicates likely cost pressures facing NHS organisations include:
- Impact of 2008/09 pay review body recommendations - individual financial plans for 2008/09 included provision for pay awards generally averaging 2.5%. The main actual awards made for 2008/09 varied from 2.2% to 2.75% and the detailed financial impact upon individual NHS organisations will have varied according to their staff mix. For example, those with high levels of Agenda for Change staff, such as ambulance trusts, will have needed to set aside additional financial provisions as a result of their overall cost of pay awards being above their initial 2.5% assumption.
- Uncertainty around the introduction of International Financial Reporting Standards (IFRS) - from 1 April 2009, These standards are being introduced to all public sector organisations and may require organisations to include assets funded through private finance to appear on individual organisations' balance sheets. These could be subject to annual depreciation charges to reflect the decline in assets' worth and a capital charge, currently set at 3.5%, to reflect the opportunity cost of tying up public resources.
Additional factors for 2009/10 and 2010/11 have been identified as creating particular cost pressures in 2009/10:
- The continued achievement of waiting time targets such as the 18 week referral to treatment target and 2 week cancer waiting time targets
- Introduction of the new SAS contract - the new contract was introduced on 1 April 2008. In 2009/10, organisations will face costs of £76m due to the contract's implementation
- Rises in referral levels during the first quarter of 2008/09 of generally between15 per cent and 20 per cent
- Pay progression - individuals are awarded annual increments over and above their annual pay award. Most organisations recognise that this effect will only last until the effect of staff turnover and 'churn' offsets the cost of annual increments being awarded. However, the introduction of new contracts during 2003 and 2004 for most NHS staff, including consultants, means that this process is still being felt.
- The double impact of fuel price rises through rising staff mileage rates as well as a significant rise in energy prices for what is traditionally a large, geographically dispersed and varied estate. Revisions to mileage allowances alone will create an additional cost pressure of £17 million
- Inflation in the cost of fuel, drugs, food and other goods and services has put significant pressure on affordability
- European Working Time Directive (EWTD) - some provider organisations pointed to cost pressures from the impact of the EWTD upon junior doctors' hours
- VAT now payable on agency staff under Employment Agencies Act
- Agenda for Change multi-year deal, year two arrangements - 2.54 per cent cost pressure on the NHSPRB pay bill due to agreed 2.45 per cent uplift to the pay scales in addition to the removal of the minimum point on the pay scale and additional increases to pay points in bands 5 and 6.
The ability of NHS trusts to fund a pay award in excess of the levels incorporated within existing financial plans varies between sectors.
All organisations should expect to, and have indicated, that small variations in pay awards from planned levels would generally be manageable within day-to-day operational contingencies as was the case with the slightly higher level of 2008/09 award.
However, the majority of acute, mental health and ambulance trust income is determined actually or notionally by the nationally set tariff uplift. Therefore such organisations face a significant risk that future pay awards for NHS staff will be higher than accounted for in the tariff uplift and a large additional cost pressure would be created for those organisations unless, as is not traditionally the case, the rate of tariff uplift is revisited.
Significant increases to future pay awards would therefore require the revisiting of operational financial plans and the potential for direct patient care, service quality or nationally set access targets to be jeopardised. In this respect, as an indication only, a 1 per cent variation in anticipated pay awards would predominantly absorb many trusts total operating contingencies and working capital reserves without any consideration for other in-year financial risks arising.
PCTs however, advised that the level of financial exposure associated with annual pay awards is not as great for PCTs as it is for other NHS organisations. This is due to the fact that direct pay costs only account for approximately 10 per cent of a typical PCTs expenditure baseline. PCTs with a large provider arm will have a greater exposure against direct pay costs but certainly not at levels of between 65 per cent and 80 per cent as seen with acute, mental health and ambulance trusts.
The new contract for Staff and Associate Specialist (SAS) doctors applies to over 2000 Whole Time Equivalents (WTE), associate specialists, approximately 5,000 staff grades and 1,600 other staff grade doctors. The implementation date for the new contract was 1 April 2008 and it is anticipated that the transfer of existing SASC staff will take place during the financial year 2008/09. Under the new contract, specialty doctors have access to incremental scales, worth 5 to10 per cent and associate specialists 3 to 9 per cent. An increase is also received on 1 April for the first two years that relates to the contracts' implementation.
Specialty doctors will receive:
- An average increase on basic pay of 5 per cent in 2008/09 and 2009/10, solely as a result of the new contract's implementation. Depending on current incremental points, individual increases will range from 4 to 8 per cent in year one and 2 to 6 per cent in year two
- An average increase in 2008/09 of 6.6 per cent and 8.8 per cent in 2009/10 as a result of the increases awarded as part of the new contract implementation and incremental progression. Individual pay increases will range from 3.7 per cent to 13.5 per cent in year one and 2.1 per cent to 14.8 per cent in year two.
Associate specialists will receive:
- An average increase on basic pay of 1.8 per cent in 2008/09 and 3.5 per cent in 2009/10, as a result of the new contract's implementation alone. Depending on current incremental points, individual increases will range from up to 4.6 per cent in year one and up to 9.1 per cent in year two.
- An average increase in 2008/09 of 2.6 per cent and a further 1.6 per cent in 2009/10, as a result of the increases awarded as part of the new contract implementation and incremental progression. Individual pay increases will range from up to13.1 per cent in year one and up to a further 4.4 per cent in year two.
- These figures do not include the increase received due to the re-basing of the contract from 38.5 to 40 hours in the new contract which results in a 4 per cent increase.
These figures do not include any future headline pay awards and percentage increases relate to increases on 2008/09 salaries prior to transfer to the new contract.
All hospital doctors continue to have access to incremental pay scales. For newly appointed consultants these increments are worth an average of 4 per cent of basic pay, excluding any clinical excellence awards.
In the financial year 2010/2011, specialty doctors and associate specialists will have access to incremental progression every year or once every two or three years, depending on their position along the pay spine:
- Doctors in the SAS grades benefit from average increments of between 3 and 10 per cent of basic pay.
- Doctors in training grades receive incremental increases of between 4 per cent and 8 per cent.
It is important that these additional increases in basic pay are factored into decisions about the recommended level of uplift.
The total NHS workforce decreased for the first time since 1997 in 2006 and decreased again in 2007 by 0.6 per cent. The total headcount was reduced by 7,670. Of 1.2 million hospital and community staff (HCHS) employed in the NHS, 94,638 are doctors, making up 8 per cent of the workforce.
Against this background, the medical and dental workforce continued to grow during 2007, although at a slower rate than in previous years. There were 87,533 FTE HCHS medical and dental staff in September 2007, compared to 85,975 in 2006. These figures show an increase of 1,588 full time equivalents (FTE) or 1.8 per cent. Since 1997, the number of FTE HCHS medical and dental staff has increased by 53 per cent from 57,099.
Figures for consultants showed that there were 33,674 consultants, the highest figure ever, but that the growth rate had slowed from an average annual rate of 2.4 per cent over the previous 10 years to 1.1 per cent from 2006 to 2007. The slowest growth rate was seen in the doctors in training cohort which increased by 1.1 per cent, compared to an average rate of 4.4 per cent over the preceding 10 years. The reduced rate of growth does not arise from a reduction to the supply of doctors but a change in the length of time a doctor spends in training. The number of English medical school graduates has increased year-on-year since 2001/02 and is expected to reach 5,800[2] in 2008/09.
Over the last ten years the number of associate specialists and staff grades has increased by an average of 8 per cent and 9 per cent respectively. In 2007, associate specialists increased by 7.7 per cent and staff grades by 2.0 per cent. The continued growth in the associate specialist workforce is due to the introduction of the new SAS contract and the closure of the associate specialist grade which will take place at the end of 2008/09.
The NHS Information Centre produces a quarterly publication of NHS staff earning estimates which show a breakdown of medical workforce earnings by staff group, taken from the Electronic Staff Record (ESR). Roll out of the ESR is now complete and the most recent data represents 99 per cent NHS organisations.
Changes in the average earnings by staff group can be due to actual increases in individuals' pay due to pay awards and incremental progression, or changes in the composition of the workforce due to pay reforms and/or the impact of new organisations joining the sample. A separate analysis of earnings has shown that some of the changes in earnings are due to changes in the sample rather than true changes in average salary.
The following figures are taken from the NHS staff earnings estimates in June 2008. They represent basic pay and total pay from the first quarter in 2008 (see table 1 in the full evidence report for comparisons with the same quarter of 2007).
Foundation year 1 trainees receive an average basic salary of £21,600 and their average total earnings are £31,500. These figures show an average additional earnings equivalent to £9,900 or 46 per cent of basic pay. Their average basic pay has increased by 3.3 per cent since the previous year whilst total earnings have gone down by 1.3 per cent. The reduction in total earnings is probably due to a reduction in the banding supplements, reflecting the 48-hour working week limit introduced through the Working Time Regulations.
Foundation year 2 staff receive an estimated basic pay of £29,100 and total pay of £43,000. These figures equate to average additional payments of £13,900 or 48 per cent of basic pay. Figures from the first quarter of 2007 show a reduction in average earnings of 1.7 per cent, and 6.3 per cent in basic and total pay, respectively.
Specialty registrars earn an average basic salary of £36,200 and an average total salary of £56,100. The estimated average additional earnings for this group add 55 per cent to their basic pay. These figures show a 5.5 per cent and 6.5 per cent reduction on the 2007 figures.
Apparent reductions in the average salaries of FY2/senior house officer (SHO) and registrar grades are not the result of real reductions in earnings. Implementation of the Modernising Medical Careers programme has resulted in most staff transferring from the SHO to the registrar pay scales. The resultant effect of this has been to reduce the average earnings of both the FY2/SHO group and registrar staff groups in the earnings estimates. A better indication of individual increases received by doctors in training is given by the annual pay awards and increments received as set out above.
Associate specialists have a mean basic salary of £73,000 and a mean total salary of £79,400. This figure represents an increase of 9 per cent on basic pay or an average £6,400 in additional earnings. The median salary is higher than the mean basic and total pay suggesting a positive skew in associate specialist earnings. Staff grades are estimated to earn a basic salary of £56,100 and an additional 10 per cent in additional pay. Their average total earnings equate to £61,900. Individual comparable figures for staff grades and associate specialists do not exist from the previous year but when grouped together, staff grade and associate specialist salaries have increased by 4.7 per cent in basic pay and 6.6 per cent in total pay over the twelve month period from the first quarter of 2007.
There are two types of contractual arrangements in place for consultants, referred to as '2003' and 'pre-2003'. 93 per cent of consultants are being paid on the 2003 contract. The mean total earnings of consultants is estimated at £115,400, for those on the 2003 contract and £98,900 for those on the pre-2003 contract, including Clinical Excellence Awards. These figures are payments received from NHS organisations only and do not include private earnings or earnings of consultants paid by universities. For those on the new contract, the total earnings have increased by 3.3 per cent over the year from the first quarter of 2007 to the same period in 2008, reflecting the pay award and increments. Analysis of the data has shown that the figures presented are a true reflection of the increase in earnings and are not skewed due to changes in the ESR sample. The increase exceeds the pay award reflecting increment increases.
Doctors earnings were compared to national levels of pay across the private and public sectors and across other professional groups in the DDRB 37th report, 2008. Doctors' and dentists' remuneration compared favourably with other professional groups, excluding actuaries who were considered a special case due to their financial services sector involvements. It was also noted that the lowest spine point for consultants is in the top 5 per cent of the national pay distribution.
Earnings for foundation doctors in training at the start of their postgraduate medical careers compare favourably with those of graduate recruits in other sectors.
Average earnings, excluding bonuses, rose by 3.7 per cent in the year to July 2008, unchanged from the three months to June 2008. Average earnings, including bonuses or regular pay, rose by 3.5 per cent in the year to July, up 0.1 per cent from the previous period.
In the year to July, pay growth (excluding bonuses) in the private and public sector stood at 3.7 per cent. Including bonus payments, private sector growth stood at 3.5 per cent, compared with 3.3 per cent for the public sector.
Medical staff turnover statistics (Medical staff turnover 2005/06, NHS Information Centre) show that the turnover rate for all medical staff (excluding doctors in training) leaving the NHS was 10.1 per cent from September 2005 to September 2006. Consultants have the lowest turnover rates at 6.3 per cent whilst hospital practitioners and clinical assistants have the highest turnover rate of medical staff groups at 24.8 per cent. 18 per cent of the turnover from the medical and dental workforce was from those aged 60 and over. The turnover rate for non-medical staff was slightly higher over the same time period at 10.9 per cent.
The latest survey of absence and labour turnover form the Confederation of British Industry (CBI) showed that national turnover rates in 2007 were 14.7 per cent. Turnover rates between sectors ranged from 31 per cent in retail to 13 per cent in the public sector. Consultants' and associate specialists' turnover rates are lower than the overall public sector but rates for other grades of doctors and dentists are higher, reflecting the normal movement expected among doctors in training and doctors undertaking sessional work.
Vacancies (NHS Workforce Vacancy Survey, 2007) for medical and dental staff were last published in March 2008 by the NHS Information Centre. The vacancy rate for medical and dental staff, excluding training grades, was 0.9 per cent. This rate has decreased every year since comparable vacancy data became available in 2003 when vacancy rates were 4.7 per cent. The three month vacancy rate for consultants was also 0.9 per cent. Geographically, the highest rate for medical and dental staff was in the North East SHA (1.6 per cent). For consultants, the highest rates are in the North West and London at 1.3%. The lowest rate was in the West Midlands (0.6 per cent). By specialty, the highest vacancy rates were in accident and emergency (2.7 per cent) and dental (2.3 per cent). The lowest rates were in anaesthetics and oncology at 0.4 per cent. Specific pockets of high vacancy rates are apparent by specialty at a regional level.
Vacancies in the non-medical staff groups were lower. Qualified and unqualified nursing cohorts showed the lowest vacancy rates at 0.5 per cent and 0.4 per cent, respectively. Considering all of the main non-medical staff groups, either London or the South East Coast had the highest vacancy rate in the majority of staff groups. The lowest vacancy rates were in the South West. All NHS vacancy rates were below the nationally available statistic of 2.5 vacancies per employee jobs in June 2008.
The Independent Inquiry into Modernising Medical Careers, led by Professor Sir John Tooke, published its final report on 8 January 2008. The report accepted NHS Employers analysis that it is essential to join up service planning, workforce planning and training at national policy level, strategic health authority (SHA) level and local health economy level, and that decisions on these difficult areas should not be left solely to the medical profession to resolve. Work programmes with other stakeholders continue, exploring key themes such as the shape and structure of future medical training, workforce planning mechanisms, the position of international medical graduates, the role of the post-CCT doctor, and the development of leadership and management skills across the profession.
Many of the recommendations from the Tooke Inquiry were subsequently revisited in the Health Select Committee report published on 8 May 2008. NHS Employers had provided written and oral evidence reaffirming that employers have a shared aim with the medical profession of ensuring that the best candidates are appointed to training places and that staff are treated fairly thrut the process. Patients need the best doctors with the highest quality training and there is no doubt the old system of training needed reform. In retrospect it was easy to see that some things in 2007 could have been done differently. Clarity of objectives and governance, longer lead-in times, wider testing of some elements and better communications would all have made a difference.
Much of this was addressed and improved late in 2007, after the MTAS system was suspended, and again during the 2008 recruitment process. Employers reported that they have appointed many excellent specialty trainees. The longer term effect on the morale of doctors in the transition cohorts is yet to be assessed, however we know that many trainee doctors were appointed to their preferred location or specialty, and the postgraduate medical education training board (PMETB) trainees survey confirms improving satisfaction with the quality of training under MMC.
The 2007 NHS Staff Survey, reporting in March 2008, indicates that doctors and dentists are more likely than their colleagues in other occupations within the NHS to report that they are satisfied or very satisfied with their level of pay. Indeed, when compared to their non-medical colleagues, doctors and dentists are more satisfied with their pay, less likely to be planning to leave their trust, more satisfied with their jobs, healthier, get better access to training and learning, are safer and less stressed, although report experiencing a poorer quality of life than the average for all NHS staff.
The NHS Staff Survey asked a number of questions relating to staff satisfaction with different aspects of their employment. The average score for job satisfaction (ranging from one for very dissatisfied staff to five for very satisfied) was 3.44. Doctors and dentists scored 3.49, compared to scores of 3.40 in 2006; consultant medical/dental staff scored a little higher on this measure at 3.51; as did doctors/dentists in training, scoring 3.53.
On individual questions related to job satisfaction, doctors and dentists generally scored higher than average. 77 per cent were satisfied with the support they received from colleagues compared to 75 per cent of all staff; 77 per cent were satisfied with the amount of responsibility they were given (68 per cent for all staff); 73 per cent were satisfied with the opportunities they had to use their skills (64 per cent for all staff); 48 per cent were satisfied with their level of pay (30 per cent for all staff).
A further measure of job satisfaction is provided by the three questions asked annually relating to the intention to leave current jobs or search for new positions. The responses for doctors and dentists show a significantly lower level of intent to leave than the all staff average. In response to the statement 'I often think about leaving this trust', 26 per cent of doctors and dentists agreed compared with 36 per cent of all staff. Asked if they would be looking for a new job within the next 12 months, 19 per cent answered yes compared to 24 per cent of all staff. Only 12 per cent of doctors and dentists agreed with the statement, 'As soon as I can find another job I will leave this trust' compared to 18 per cent of all staff. 20 per cent of consultants and of SAS doctors have 15 or more years service at their current employer suggesting stability in the workforce compared to other NHS occupations.
When asked if they have suffered 'work related stress' in the preceding 12 months, 26 per cent of all medical and dental staff say they had, compared to 33 per cent of all NHS staff.
In relation to work-life balance, doctors and dentists' responses indicate that job flexibility and the opportunity to balance their working and home lives are not always as accessible as for other colleagues. 33 per cent felt their employer was committed to helping staff balance work and home life compared to 40 per cent of all staff; 40 per cent felt their line manager helped them to find a good balance (53 per cent of all staff) and 51 per cent felt they could approach their line manager to talk about flexible working (63 per cent of all staff).
Thirteen per cent of all staff had personally experienced physical violence at work in the last 12 months either from patients or their relatives. The figure is lower for doctors and dentists at 7 per cent. These figures have remained stable for three years.
There are no significant differences in figures for bullying and harassment of doctors and dentists from those of other staff groups, with bullying, harassment and abuse by patients standing at 23 per cent and by relatives of patients at 18 per cent. In relation to experiencing bullying and harassment from colleagues, the average for doctors and dentists is 15 per cent, and for all NHS staff is 17 per cent.
Employers in the NHS in England considered the four most important factors for assessing pay recommendations should be:
- the financial position of the trust
- recruitment and retention
- the level of the tariff
- staff morale.
Employers are very clear that any cost pressure through unfunded pay increases would have an adverse affect on services. Most employers indicated that an unaffordable pay increase would lead to necessary cost savings elsewhere. The four most likely consequences given by employers were:
- a reduction in the quality of services
- delayed planned expansion of services
- a reduction in the number of posts
- failure to meet targets set by government.
Affordability is linked to the level set for pay in the tariff. Employers have to be able to meet commissioned levels of service and national targets without compromising patient care or financial balance. Similar financial constraints will apply to PCTs and some mental health services, even though they are mainly not covered by the tariff prices. Affordability of pay awards can be compromised by assumptions of efficiency gains which may be more difficult to achieve in some places rather than others.
Employers reported whether they faced recruitment and retention difficulties during the past year, the grade and speciality involved, and whether any difficulties were severe or not. Half of the trusts responding to the questionnaire reported recruitment and retention difficulties in relation to doctors and dentists, over the year to August 2008, and just over 10 per cent of them reported a total of 35 doctors and dentists recruitment difficulties as 'severe'. Most common among the specialty areas involved in those 35 examples were A&E (five examples),haematology (four examples), anaesthetics (four) and salaried dentists (three). Thirty two of the severe difficulties were related to labour shortages, the other causes being said to be location (in one case) and MMC (in two cases). Many of the labour market difficulties may have been generated by the short term locum shortage caused by the changes to the doctors in training recruitment system, coinciding with changes to UK immigration arrangements which may have affected the potential supply of overseas trained doctors.
Pay was not cited in all the difficulties reported by employers, except in relation to salaried dentists. The new contract for this group was only implemented in the spring of 2008 and it remains too early to confirm its effect.
The most common approaches reported as in use by employers to solve recruitment and retention problems were:
- the use of locum cover (both from external agencies and internal arrangements)
- job plan changes
- skill mix changes
- overseas recruitment.
A small number of employers reported the use of local labour market supplements.
Non-pay measures in use at employer level to aid recruitment and retention were:
- flexible hours working
- flexible retirement arrangements
- childcare support
- career breaks schemes
- annualised hours
- term time only working
- return to practice arrangements
Employers are strongly of the view that medical and non-medical staff should have an award that extends to the end of the comprehensive spending review period. However, any multi year award would need to be at an affordable level, with a corresponding uplift to the tariff. It could also be assumed that such an award could only be accommodated within the limits of public sector pay policy. A minority prefer that economic and market conditions be assessed annually.
About half of the employers returning the questionnaire report seeing benefits from pay reform quoting most often:
- improved working practices
- reductions in waiting times
- improvements in productivity,
- improved team working
- improved recruitment and retention.
The majority of employers have indicated to us that they would prefer a percentage increase rather than a flat rate increase for medical staff. They have told us that they do not believe extra pay should be targeted at any particular medical or dental groups.
London weighting
Half of the responses to the questionnaire expressed an opinion on whether the level of London weighting was adequate, and 80 per cent of those employers thought that it was adequate, although in London based trusts this view was held by 66 per cent of the responses.
Taking all of this into account, NHS Employers, on behalf of employers of doctors and dentists in the English NHS, would like to see a fair and reasonable national pay award that recognises the need for local employers to achieve financial balance and is consistent with the resources available to the NHS and reflected in the 2009 tariff uplift.
The tariff has not yet been published making it difficult for employers to make an accurate assessment of affordability. However, it is clear that organisations will have to deliver efficiency gains over and above the CSR three per cent target to finish the financial year in balance. This conclusion is based on headline pay awards in line with public sector pay policy restrictions of two per cent in addition to cost pressures of 1.6 per cent on pay budgets.
Taking into account the impact on staff, it is therefore suggested that an award of two per cent is affordable.