Junior doctors’ pay—is it time to change the agenda?
Authors: Yasmin Ahmed-Little, Mark Johnston, Howard Sunderland
Publication date: 04 Jun 2008
With the European Working Time Directive set to change junior doctors’ hours Yasmin Ahmed-Little, Mark Johnston, and Howard Sunderland look at whether it might be time to change their pay scales
With the reality of a 48 hour week looming and by default band 1 jobs for all, is there a need to revisit the current pay structure for junior doctors? There are calls for a review of the current junior doctors’ contract from national European Working Time Directive leads. The contract is no longer considered fit for purpose, since it is based on traditional on-call working patterns and most junior doctors now work full shifts. Changes in postgraduate medical education towards competency based training beg the question whether any new contract should rest on competency based progression. Given the NHS already operates a competency based pay structure for all other NHS staff, is the answer staring us in the face? Should junior doctors be paid according to Agenda for Change (AfC), a pay scale that is transparent and equitable, ensuring a fair pay system for all NHS staff?
What is Agenda for Change?
Historically, the NHS has had several pay structures for different staff, conferring varying levels of benefits with no single, standard approach for people working for one employer. A large step was taken towards rectifying this with AfC, agreeing for the first time a single pay structure applicable to all NHS staff, except very senior managers and staff within the remit of the Doctors and Dentists Review Body. The final agreement for AfC was published by the Department of Health and implemented across the NHS in December 2004.
What happens when you apply AfC to junior doctors?
AfC job evaluation assessment is based on the scoring of 16 factors using information from the job description and personal specification of the post. Each of these scores is then weighted, giving an overall total which allow the appropriate pay band to be allocated. The first three factors alone (communication and relationship skills; knowledge, training, and experience; analytical and judgment skills) are heavily weighted. Most junior doctors should score highly in these areas.
Formal matching by trained assessors within the team using the NHS Job Evaluation Handbook  showed a generic specialist registrar/senior specialist trainee grade post would fall at a minimum into band 8b on the AfC pay scale, moving up to band 8c depending on specialty specific requirements. Predictions for foundation year 1 trainees are that the minimum AfC band would be 7. When evaluating senior house officer/junior specialist trainee grades the results span across bands 7 and 8a, dependent again on specialty based requirements. Within certain AfC indicators—for example, physical skills—posts in surgical based specialties may score higher.
AfC pay scales are based on a standard 37.5 hour working week excluding lunch breaks. Junior doctors are contracted for a basic working week of 40 hours including paid breaks. To assess the financial implications of this, AfC bands 7 and 8 pay scales were compared with the 48 hour junior doctor pay bands. The midpoints on the November 2007 junior doctor and AfC pay scales were used. The tables on this page show the results.
The published AfC pay scales relate to a 37.5 hour week. Pro-rata salaries for a 48 hour working week have been extrapolated based on current hourly rates. The assumption, therefore, is that junior doctors could be contracted to 48 hour weeks under AfC and paid according to current hourly rates calculated based on a 37.5 hour week. The continuation of a 48 hour working week, for more senior trainees at least, is likely to be deemed necessary to support postgraduate medical training to achieve the certificate of completion of training. It should also be noted, however, that under the current AfC contract those in bands 8 and 9 are not entitled to overtime payments. This may have to be challenged for doctors contracted to work more than 37.5 hours regularly compared with existing provisions made to accommodate incidental overtime hours.
All current foundation year 1 doctors and specialist registrars/senior specialist trainees at bands 1a, 1b, or 1c on the national junior doctor contract would benefit from moving to AfC at the minimum predicted AfC bands suggested here. In specialties where additional skills and responsibilities would attract a higher AfC banding there is a clear and undisputed financial advantage. The addition of enhancements would incur further financial reward. Senior house officer/junior specialist trainees in specialties which may match to AfC band 7 could be disadvantaged. However, this should be offset by the addition of out of hours enhancements which are likely to be worked at this level.
Overall the benefits of implementing AfC for junior doctors may be considerable. The loss of band 3 claims and banding appeals associated with the juniors’ current contract would save considerable NHS resources and rebuild employer-employee relations. Contractual biannual monitoring of working hours is a labour and resource intensive task which is troublesome for both trainees and trusts. Replacing this exercise with European Working Time Directive breech exception reporting, in line with other NHS staff, would be welcome.
Furthermore, the inflexibility of New Deal rules has had a considerable detrimental impact on training. This is most apparent within surgical specialties, where, for example, the maximum continuous duty period of 32 hours on weekdays and 56 hours at weekends within an on-call rota have led to many trusts enforcing full or half days off following on-call duties at the cost of attendance at clinics, theatres, and so on. Worse still, successful band 3 claims on such rotas have led to implementation of full shift working, where the subsequent decrease in exposure to a normal working day is disastrous for surgical training. The structure of the current junior doctors’ contract itself has encouraged many organisations to remove out of hours working from foundation year 1 rotas, something that could be remedied by a contract with less emphasis on out of hours pay supplements.
Monthly salary implications
Whereas juniors currently receive a standard monthly salary, under AfC this may vary according to the amount of work done each month. However, the variation may not be important enough to hinder sensible financial planning and could improve fairness with more accurate representation of individual working hours. The trainee who ends up working more night shifts than colleagues and who under the current contract is paid the same, with AfC would see the financial reward in their pay packet at the end of the month.
Aside from the operational benefits, the wider NHS would undoubtedly benefit from the consistency and morale boosting action of ensuring most of its hospital staff benefit from the same rules and standards of one shared contract. Such harmonisation supports the human resources modernisation agenda and devolution of medical staffing functions to directorate/divisional level. Medical staffing support for juniors itself may improve if confusion between the need to comply with the different rules of the New Deal and European Working Time Directive is removed, and may lead to better rotas and more synergy with health and safety aims.
However, implementation of any new contract is never cost neutral. Although national cost savings can be realised by avoidance of negotiating and implementing an entirely new contract for juniors, AfC matching of roughly 37 000 posts will require considerable resources as well as costs entailed in associated salary rises. Following Modernising Medical Careers, updated personal specifications approved by the Postgraduate Medical Education and Training Board are available for all junior doctor posts. However, job descriptions in most instances are not. These may be required for AfC matching purposes following current guidance. Areas such as paid “natural breaks” for junior doctors would need further consideration. It should also be noted that not all rotas are rostered up to the maximum 48 hour limit, which may reduce take home pay under AfC.
The table above shows the range of NHS posts currently within AfC bands 7 and 8 in which junior doctors might work. Some time spent leading a hospital at night team at AfC bands 8a-8c may be worth considering for juniors if unemployment is the alternative. Development of Hospital 24/7 models could create appreciable expansion in these posts. The NHS and patients may benefit from juniors undertaking such roles, minimising the burden on the nursing workforce while supporting the development of generic competencies. The work-life balance accompanying a 37.5 hour working week may be happily traded for a reduction in overall salary but increase in hourly wage.
Change is needed.
Compared with other NHS staff, junior doctors may currently be being underpaid and undervalued. This is further exacerbated by the fear of future mass unemployment. A failure to tackle these issues in a timely manner threatens recruitment and retention of our future medical workforce. Salary differences have become apparent as overall working hours for junior doctors are falling, affecting take home pay. To achieve true equity across NHS staff and deal with the deficiencies of the current junior doctor contract, there may be a need to Agenda for Change junior doctors.
Competing interests: All three authors are junior doctors.
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Yasmin Ahmed-Little junior doctor and project director of the EWTD Medical Workforce Development Team
Mark Johnston junior doctor and assistant director of the EWTD Medical Workforce Development Team
Howard Sunderland junior doctor and medical adviser to the EWTD Medical Workforce Development Team NHS North West, North West Deanery, and Mersey Deanery