Policy paper

The Department of Health and Social Care's written evidence to the Doctors' and Dentists' Remuneration Body (DDRB) for the pay round 2023 to 2024

Published 21 February 2023

This was published under the 2022 to 2024 Sunak Conservative government

1. NHS Strategy and introduction

This chapter sets out the wider context for the department’s evidence for the 2023 to 2024 pay round and provides an overview of this year’s written evidence to the Review Body on Doctors’ and Dentists’ Remuneration (DDRB).

This follows the 2022 to 2023 pay round, in which the government looked to the DDRB for a recommendation on pay for staff not in multiyear deals, and after careful consideration, and reprioritisation of existing departmental funding, accepted the recommendations in full. This year, the government is again inviting the DDRB to make a pay recommendation for doctors and dentists not in multiyear deals.

The NHS Spending Review settlement

In the challenging economic and fiscal context in which pay recommendations will be made this year, decisions on pay awards will have a particular impact on the spending review settlement and the commitments made within it. In addition to the long-term NHS settlement announced in 2018 and the additional funding announced at the last Spending Review (SR21), funding confirmed at the 2022 Autumn Statement means the NHS resource budget will increase to £160.4 billion in 2023 to 2024, and to £165.9 billion in 2024 to 2025, up from £123.7 billion in 2019 to 2020.

Since the evidence we provided last year, the context in which the NHS operates has been rapidly changing. The prolonged impact of the COVID-19 pandemic has been significantly higher than assumed in SR21, with more COVID-19 patients occupying beds in 2022 than in 2021 or 2020. This will continue to have consequences for the productivity of services and bed occupancy rates. Inflation has been much higher than previously forecast. At the time of SR21 inflation was forecast to peak at over 4% but, due to higher energy prices and the invasion of Ukraine, looks to have peaked at just over 11% this winter (His Majesty’s Treasury (HMT) have provided further evidence on the economic outlook). While the government has continued to prioritise investment into the NHS, these factors have increased the costs of delivering services, and the financial pressures systems are facing. Due to these changes, and last year’s pay award being significantly above the government’s affordability envelope, NHS England (NHSE) is undergoing significant reprioritisation.

The Chancellor’s Autumn Statement 2022 reiterated the government’s priorities on delivering the long-term plan (LTP), improving health outcomes for patients by ensuring the NHS can tackle the elective backlog, and having the resources to continue its response to the COVID-19 pandemic. As was covered in last year’s evidence, SR21 specifically included:

• around £8 billion to tackle the elective backlog - a significant part of this funding will be invested in staff - both in terms of capacity and skills
• additional funding to grow the NHS workforce - there are currently 72,000 nurses in training and over 9,000 people training to be midwives, as well as a record number of medical students in training
• £9.6 billion over the SR period for COVID-19 related health spending

Chapter 2 of our evidence focuses on how the changing context has impacted the department’s settlement and how NHS finances are being targeted at meeting key priorities.

Overview of the NHS workforce

The NHS settlement has been carefully prioritised to ensure that the NHS can meet these key priorities and keep growing a diverse, skilled NHS workforce within a challenging fiscal context. Chapter 3 of our evidence outlines the department’s current strategy to ensure that the NHS has the workforce it needs. The government has committed to publishing a comprehensive workforce plan in 2023 and this will include independently verified forecasts for the number of doctors, nurses and other professionals that will be needed in 5, 10 and 15 years’ time, taking full account of improvements in retention and productivity. Alongside this, we are investing in and diversifying the training pipeline to increase the supply of doctors. There is also significant reform taking place in the health and care system to improve integration of services around the needs of patients.

‘Our plan for patients’ focuses on the challenges facing the NHS this winter and next: and our expectation is that the focus will largely be about delivery and access to care, given the pressures on the system and the effect of winter. We recognise that the plan will require staff to work differently - for example, with staff in GP practices taking on a different range of activity to free up GP time - or using all the staff employed by dental practices to the fullest extent of their professional qualifications.

Work is also underway to identify the NHS’s more wide-ranging strategic priorities - with further detail set out in NHSE’s Planning Guidance and other documents to be developed in due course.

Recruitment and retention are not only crucial to meeting objectives like elective recovery but for safeguarding staff health, wellbeing and morale and avoiding burnout. It is important to recognise the great strain the COVID-19 pandemic has placed on the health and social care workforce, and the exceptional response of those working in health and social care throughout this period. The government recognises that staff are also motivated by their workplace environment and culture, championing inclusion, diversity and prioritising health and wellbeing.

Chapter 4 sets out how the workforce has changed in the last year, outlining the current data and analysis on joiners, leavers, vacancies, and temporary staffing in the medical and dental workforce. Alongside chapter 3, it outlines that overall the workforce continues to grow, with a record and growing number of doctors and steady progress for dentists. However, there is more to do, and our evidence outlines the current and additional steps the government and our NHS system partners are taking to increase morale and motivation during a challenging time for the workforce.

The NHS total reward offer remains a key recruitment and retention tool in ensuring the NHS can grow the workforce it needs. Pay makes up one part of the overall reward package and, while important, there are other benefits which have both financial and non-financial value which impact the motivation, recruitment, and retention of the NHS workforce. Chapters 5 and 6 of our evidence provide more detail of the total reward package and describe how earnings for the medical and dental workforce have remained broadly competitive against the wider economy and comparable labour markets, growing in line with expectations following last year’s pay uplift. Medical staff have high salaries compared to the wider economy and most staff groups have stayed in a similar position within the general income distribution.

The government needs to strike a careful balance between ensuring the NHS has the workforce it needs to deliver health priorities and ensuring the NHS delivers value for money for the taxpayer. The 2021 Spending Review set efficiencies targets for the NHS of 2.2% per year through to 2024 to 2025. This does not include the requirement for systems to operate with reduced COVID-19 funding (by 57% in 2023 to 2024 - from £5.1 billion to £2.2 billion). In this context and with significant inflationary pressures, there is a need for even stricter prioritisation of budgets. The large size of the NHS workforce makes the impact of further pay pressures greater. Any additional funding needed for pay awards will need to be found through further reprioritisation of the existing budget and there are stark trade-offs between pay and other NHS spending.

Pay rises above affordability could materially impact the government’s ability to deliver on key priorities, such as manifesto commitments and the elective recovery. It is therefore essential during this challenging fiscal and economic climate that pay remains fair, to recognise the vital importance of NHS staff, but affordable, to minimise inflationary pressures and help manage the country’s debt. We urge DDRB to carefully consider this important balance when reaching your recommendations. Further information will also be provided at oral evidence.

We look forward to receiving your report in April 2023.

2. NHS finances

This chapter describes the financial context for which NHS pay awards will need to be met.

The focus for the NHS continues to be balancing the priorities of managing the ongoing COVID-19 response and addressing the elective recovery challenge. NHS financial sustainability is essential to achieving these objectives.

In the challenging economic and fiscal context in which pay recommendations will be made this year, it is important that the DDRB understand the impact of pay awards on the SR21 settlement and the commitments made within it. Funding for NHS pay is considered alongside other categories of budget. The health and social care system is in an extremely challenging position, with cost pressures resulting from the prolonged impact of the COVID-19 pandemic in addition to the significant impact of inflation on budgets and the costs of delivering services. The health and social care workforce is much larger than comparable workforces, and the impact of the pay pressures are correspondingly greater.

SR21 delivers an additional £23.3 billion over 3 years for the NHS. This includes more than £8 billion to tackle the elective backlog, which comes on top of £2 billion funding already provided for this purpose. In addition, a further £3.3 billion in 2023 to 2024 and 2024 to 2025 was made available in the Autumn Statement 2022. Nevertheless, given the significant inflationary pressures, budgets are being stretched and will continue to be by meeting the efficiency and productivity savings as set out in SR21. It is therefore important that the 2023 to 2024 pay awards help support NHS performance in delivering long-term financial sustainability in the NHS.

Economic context

Global factors have led to a significant amount of economic uncertainty over the course of 2022 with global energy price increases being the primary driver of above-target inflation. The Consumer Prices Index (CPI) reached 10.5% in the 12 months to December 2022. CPI inflation is forecast to average around 11.1.% in Q4 2022, fall to around 5% over 2023 to 2024, before turning negative in 2024 to 2025 as fading external factors outweigh domestic pressures.

Attempts to restrain inflation have led to the Bank of England increasing their base rate to 3.5% in December 2022, its highest level in 14 years, in order to bring domestically generated cost pressures - namely nominal wage growth - down to levels consistent with their 2% inflation target. After experiencing faster than anticipated growth as the country reopened from the COVID-19 pandemic in 2021, GDP fell by 0.2% in Q3 2022. As a result of these economic conditions, the Office for Budget Responsibility (OBR) forecasts that the UK economy has already entered a recession, expected to last until 2023 Q3, the longest on record.

In this context, pay awards need to strike a careful balance between recognising the vital importance of public sector workers, while minimising inflationary pressures and managing the country’s debt. If public sector pay awards are significantly above the private sector, this could contribute to risks of higher and more persistent inflation, by placing pressure on other parts of the economy to demand higher wages. The government is committed to price stability and has re-affirmed the Bank of England’s 2% CPI target at the Budget. Given that the government’s inflation target is part of the terms of reference for the DDRB, this must be considered as part of their recommendations.

Funding growth

The NHS LTP sets out that putting the NHS back onto a sustainable financial path is a key priority and is essential to delivering further improvements in care. The COVID-19 pandemic has understandably impacted on progress towards implementing many elements of the LTP, however, as set out in the government 2022 to 2023 mandate to NHS England, we are focused on minimising the further adverse impact of the COVID-19 pandemic and then recovering delivery against commitments made in the LTP. This includes supporting the further expansion of NHS programmes and services and embedding the positive changes brought about by COVID-19 such as integration and technology advancements.

As described in chapter 1, SR21 took steps to place the NHS on a sustainable footing and to fund the biggest catch-up programme in NHS history. The increase in funding for elective recovery, growing the workforce and allowing the NHS to continue to respond to the COVID-19 pandemic will further enable the NHS to deliver better service and health outcomes for patients.

The SR21 settlement for Health and Social Care, together with the additional funding at the Autumn Statement 2022 , will also ensure that we can keep growing a diverse and skilled NHS workforce. The government is committed to delivering its manifesto commitments and funding 7,500 medical students in training every year - a record number. The settlement will also continue to support a strong pipeline of new midwives and allied health professionals, who are key to delivering the full range of NHS services.

Table 2.1: mandates for NHS England

NHS England (NHSE)	NHSE revenue departmental expenditure limits (RDEL) excluding ringfence (RF) (cash) £billion	NHSE capital departmental expenditure limits (CDEL) excluding ringfence (RF) (cash) £billion
2013 to 2014	93.676	0.200
2014 to 2015	97.017	0.270
2015 to 2016	100.200	0.300
2016 to 2017	105.702	0.260
2017 to 2018	109.536	0.247
2018 to 2019	114.603	0.254
2019 to 2020	123.377	0.260
2020 to 2021	149.473	0.365
2021 to 2022	150,614	0.337
2022 to 2023	152,555	0.223
2023 to 2024	160,420	0.219
2024 to 2025	165,860	0.219

Source: 2022 to 2023 variation to the financial directions to NHS England

Table 2.1 above shows the closing mandates for NHSE up to 2021 to 2022, the varied mandate in 2022 to 2023, and indicative amounts for future years, in line with the outcomes of SR21 and the Autumn Statement 2022. The figures are adjusted annually to account for reallocation of resource, additional funding, and changes of responsibility between government bodies. These figures include an increase for pensions revaluation which was provided alongside the LTP settlement. Figures exclude depreciation, annually managed expenditure (AME) and the technical accounting budget, namely capital grants or Private Finance Initiative.

Multiple calls are currently being made on available funding, including the knock-on impact of last year’s pay award on the total paybill cost of this and future years. As described later in the chapter, more funding put towards pay will mean less funding for other priorities, including the size of the workforce that is affordable, as well as wider non-ringfenced investments required to deliver the NHS LTP and elective recovery.

Financial position

The government’s 2022 to 2023 mandate to NHSE outlines the headline objectives for the NHS. The 2022 to 2023 variation to the Financial Directions to NHSE reflects further funding to deliver manifesto commitments agreed at Budget 2021 as well as funding to meet pressures arising due to the COVID-19 pandemic and to support the recovery of elective services in the 2022 to 2023 financial year. Following the temporary COVID-19 financial framework, the system is transitioning from block payments, which were in place to help deal with the impact of COVID-19, to blended payments.

Despite the significant challenges faced by the service, the NHS ended the 2021 to 2022 financial year in an overall underspend position. This was mainly driven by the COVID-19 Omicron variant which slowed down spending on normal NHS commissioning activity and service transformation. This led to a significant improvement in the financial position of frontline NHS organisations, with the NHS provider sector ending the year with a healthy aggregate surplus.

However, the fiscal and economic environment of the last year has pushed the NHS into a challenging financial position in 2022 to 2023 onwards. Cost pressures arising from the impact of inflation on budgets has forced the NHS to release significant reserves and savings in 2022 to 2023 . These pressures will continue to be felt, and have an impact on budgets, into 2023 to 2024. Despite the headline financial plan for 2022 to 2023 being balanced, the NHS is working to manage significant additional net financial risk, mostly driven by the continuing impact of the COVID-19 pandemic which is driving up costs and reducing capacity.

Table 2.2 shows the breakdown of funding provided to NHS providers over the last 5 years.

Table 2.2: NHS providers RDEL breakdown

NHS Providers RDEL breakdown (£million)	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
NHS providers’ RDEL outturn as per SoPS	1,038	826	1,008	-731	-589
Provisions adjustment	-39	23	50	418	320
Other adjustments	-8	-22	-159	-342	-287
Aggregate net deficit (surplus)	991	827	899	-655	-556
Unallocated sustainability funding	-25	0	-144	0	0
Adjust net COVID-19 Impact	0	0	-85	0	0
Reported net deficit (surplus)	966	827	669	-655	-556

Share of resources going to pay

Table 2.3 shows the proportion of funding consumed by NHS provider permanent and bank staff spend over the last 9 years. Note that NHS provider permanent and bank staff spend only covers staff working within hospital and community health settings.

Table 2.3: increases in revenue expenditure and the proportion consumed by paybill

Year	NHSE RDEL (£bn)	NHS Provider permanent and bank staff spend (£bn)	% of spend on staff	Increase in total spend	Increase in provider permanent and bank staff spend
2013 to 2014	93.7	42.9	45.8%	n/a	n/a
2014 to 2015	97.0	43.9	45.3%	3.57%	2.37%
2015 to 2016	100.2	45.2	45.1%	3.28%	2.80%
2016 to 2017	105.7	47.7	45.1%	5.49%	5.58%
2017 to 2018	109.5	49.9	45.6%	3.63%	4.64%
2018 to 2019	114.4	52.6	45.9%	4.46%	5.35%
2019 to 2020	120.5	55.7	46.2%	5.35%	5.88%
2020 to 2021	140.6	62.7	44.6%	16.63%	12.63%
2021 to 2022	146.5	66.2	45.2%	4.21%	5.46%

Notes:

• 2013 to 2014 to 2019 to 2020 NHSE RDEL represents the budget, while underspend was negligible. 2019 to 2020 NHSE RDEL excludes £2.8 billion for the revaluation of the NHS pensions scheme. 2020 to 2021 reflects spend and excludes £6.0 billion unspent funding and £2.8 billion for the revaluation of the NHS pensions scheme. 2021 to 2022 reflects spend and excludes £1.3 billion unspent funding and £2.8 billion for the revaluation of the NHS pensions scheme
• 2020 to 2021 NHS Provider permanent and bank staff revised since last year’s submission due to the publication of the DHSC annual report and accounts: 2020 to 2021 on 31 January 2022

In 2022 to 2023, the pay awards were significantly above the government’s affordability envelope. As a result, a significant reprioritisation exercise within NHSE has had to be undertaken to identify the funding necessary, with the consequent need to slow investment in service transformation. The DDRB recommended a 4.5% pay increase for medical and dental staff outside of multiyear deals. The NHSPRB recommended a £1,400 consolidated uplift for AfC staff, enhanced for pay points at the top of band 6 and all pay points in band 7 so it is equal to a 4% uplift. This was an impact of 4.75% on the AfC paybill - 1.75% (equivalent to £1.2 billion) above what was provisioned for pay. The government accepted and implemented these recommendations in full.

Doctors and dentists in training are currently in the final year of a 4-year pay and reform deal, covering up to 2022 to 2023. Overall investment in 2022 to 2023 was 3% with headline pay awards of 2%, with the further investment in the form of enhanced terms and conditions and a new top pay point, nodal Point 5. SAS doctors are also currently in a multiyear deal, covering 2021 to 2022 to 2023 to 2024. This agreement sets out increases to pay and amendments to the 2008 Specialty Doctor contract and introduced a new senior Specialist contract which increased the earnings potential for the workforce. Investment averages at 3% per year of the deal.

The BMA’s General Practitioners Committee (GPC) and NHSE agreed a 5-year GP General Medical Services (GMS) contract framework from 2019 to 2020 to 2023 to 2024. This agreement, along with £4.5 billion of additional investment of by 2023 to 2024, aims to expand the general practice workforce, transforming the system to address workload and retention issues and better meet patient needs.

This shows that over recent years, DHSC has embarked on both pay and contract reform across the NHS workforce. AfC staff, doctors and dentists in training and specialty doctors have all benefited from modernisation of terms and conditions and changes to pay scales to better reward increasing experience and expertise. As these reforms have illustrated, this is not just about headline pay uplifts but reforming pay structures to increase career earnings potential and delivering changes that will help improve the working lives and the physical and mental health and wellbeing of all our dedicated NHS staff.

Demand pressures

Activity and demand levels in the health system for elective care dropped dramatically in 2020 to 2021, as numbers of self-presenting patients reduced and the NHS freed up capacity to manage COVID-19 demand, including the suspension of all non-urgent elective operations. 

Demand for non-elective care in 2021 to 2022 has returned to levels seen before the COVID-19 demand spike.

Figure 2.1: total and emergency admissions per calendar day

Source: A&E attendances and Emergency Admission Statistics

Figure 2.1 shows the total and emergency admissions to NHS England per calendar day between 2011 to 2012 and 2021 to 2022.

In 2019 to 2020 there were 68,540 A&E attendances and 17,551 emergency admissions per day. In 2021 to 2022 there were 66,781 A&E attendances and 16,753 emergency admissions per day. This equates to a 3% decrease in attendances and a 5% decrease in emergency admissions between 2019 to 2020 and 2021 to 2022.

Table 2.4: total referral to treatment (RTT) pathways completed per working day

Year	RTT estimated clock starts	RTT total completed pathways and validation removals	Waiting list
2011 to 2012	59,771	59,897	2,443,952
2012 to 2013	63,085	62,150	2,677,497
2013 to 2014	66,281	64,806	3,052,280
2014 to 2015	69,473	68,853	3,209,293
2015 to 2016	73,252	71,403	3,675,298
2016 to 2017	76,348	75,476	3,897,530
2017 to 2018	78,401	77,583	4,102,999
2018 to 2019	81,392	80,434	4,345,467
2019 to 2020	78,366	78,205	4,386,297
2020 to 2021	54,926	52,696	4,950,297
2021 to 2022	73,594	68,030	6,358,050

Source: NHSE consultant led referral to treatment statistics. Data adjusted for non-submitting Trusts and exclusion of sexual health services from 2013

Compared to the year before, in 2021 to 2022 there was a 14% increase in the number of emergency admissions. There was a 28% increase in the number of completed pathways, and the referral to treatment waiting list reached 4.9 million by the end of the financial year as demand continued to outpace activity, as shown in figure 2.1 and table 2.4.

Despite the continuing best efforts of the NHS, many of the improvements between 2019 to 2020 and 2020 to 2021 in core waiting time and access targets were reversed during 2021 to 2022 or continued to deteriorate. These included A&E, referral to treatment, cancer treatment, diagnostic tests and ambulance response standards. There were improvements in recovering elective services with activity increasing throughout 2021 to 2022, although generally this remained lower than pre-COVID-19 levels.

In both ‘Build Back Better: our plan for Health and Social Care’ and ‘Our plan for patients’, the department has committed to reducing the elective backlog as part of improving NHS services going forwards. More than £8 billion has been provided over 3 years for this, which comes on top of £2 billion funding provided in 2021 to 2022 to step up elective activity and transform elective services. This funding could deliver the equivalent of around 9 million more checks, scans, and procedures. It will also mean NHSE can aim to deliver the equivalent of around 30 per cent more elective activity by 2024 to 2025 than it had delivered before the COVID-19 pandemic. 

Last year the DDRB asked about the scale of increases to care backlogs that was caused by COVID-19-related disruption to care. During the first wave of the COVID-19 pandemic activity levels dropped to around 40% of normal levels. This reduction in activity meant that patients who would have normally been treated were not, and therefore the waiting list has grown to over 7 million from 4.4 million at the start of COVID-19. Activity has been recovering to pre-COVID-19 levels and is currently just below normal levels. The Elective Recovery Delivery Plan looks to boost activity level to around 30% higher than they were before COVID-19. This extra activity would help reduce the overall waiting list in the longer term.

Calculating productivity in the NHS 

Health productivity increased on average by 0.9% per annum from 1995 to 1996 until 2019 to 2020. This is a similar level to productivity growth in the wider economy. Health productivity was lower prior to the financial crash but higher from the financial crash to the COVID-19 pandemic.

Figure 2.2: productivity growth in health and the wider economy up until 2019 to 2020. Productivity measures are indexed to 1995 to 1996 = 100.

Table 2.5: average productivity growth in health and the wider economy, both prior to and after the financial crash

Years	Health	Wider economy
Average 1998 to 2007	0.9%	1.7%
Average 2008 to 2017	1.0%	0.1%

Health productivity measures are currently only published up until 2019 to 2020 so do not reflect the full impact of the COVID-19 pandemic. However, ONS do publish public service productivity measures quarterly, allowing the effect of the COVID-19 pandemic to be observed. These measures don’t specifically identify health productivity but as health is 40% of the measure, it is an indication of health productivity.

Although public service productivity has remained mostly steady since Q2 2021 (April to June 2021), it is still 6.5% below the pre-COVID-19 level. The volume of inputs and outputs remains higher than pre-COVID-19 levels due to an increase in expenditure and activity in response to COVID-19. However, while inputs have seen a 12.1% growth compared with pre-COVID-19, outputs have only seen a 4.8% growth.

While public service productivity remains at low levels, this creates challenges for the NHS. As a result of the COVID-19 pandemic, there are currently large backlogs for elective care. Reductions in productivity result in reductions in outputs in the NHS, which means less of the elective backlog can be tackled.

It is important to note that infection controls and lockdowns implemented throughout the COVID-19 pandemic have delivered health benefits (for example, less COVID-19 cases) that will not be captured in our usual measures of productivity.

Productivity and efficiency in the NHS

The government has set out in ‘Build Back Better’ that recovering and increasing productivity will be crucial to restoring the performance of the NHS. In ‘Our plan for patients’, the department re-committed to improving productivity and identified backlogs as one of 4 key priority areas. In February 2022, the NHS published the delivery plan for tackling the COVID-19 backlog for elective care setting out a clear vision for how the NHS will recover and expand elective services over the next 3 years. The plan commits the NHS to deliver 9 million additional elective treatments and diagnostic procedures over 3 years and around 30% more elective activity than it was doing before the COVID-19 pandemic by 2024 to 2025.

Public sector productivity as a whole fell by 35.7% at the start of the COVID-19 pandemic, as estimated by ONS (between April and June 2020 compared with the same quarter a year earlier). See more information on the ONS website. The latest ONS public services productivity publication estimates that in Q2 2022 (April to June) public service productivity is still 6.5% below the pre- COVID-19 level, but this has remained mostly steady since Q2 2021. They estimate that healthcare specific output excluding Test, Trace and vaccination has recovered to pre-COVID-19 levels.

Revised infection, prevention and control (IPC) guidance was issued to NHS organisations by NHSE in April 2022, and further revised again in June 2022. This included: stepping down inpatient COVID-19 isolation precautions by allowing isolation period to be reduced from 10 to 7 days with 2 negative LFTs; and stepping down COVID-19 precautions for exposed patient contacts, with removal of need for inpatient close contacts to isolate. These changes have helped the NHS to increase activity, while keeping patients safe.

IPC rules have relaxed due to the success of vaccination programmes and a reduction in COVID-19 cases in 2021 to 2022. However productivity is yet to fully recover to pre-COVID-19 levels due to issues such as:

• the combined prevalence of flu and COVID-19 in communities
• staff absence (due to COVID-19)
• use of agency staff and wider vacancies

The NHS is committed to implementing the UK Health Security Agency (UKHSA) IPC guidance consistently and safely and in doing so move towards delivering services in a more productive way. Any adjustments to these measures will be dependent on emerging COVID-19 variants and seasonal flu.

As part of the £8 billion funding announced at the spending review, the government has invested in programmes to help the NHS achieve an ambitious productivity trajectory while delivering on the elective recovery challenge. The key productivity programmes prioritised by NHS England are:

• improving patient pathways - simplifying a patient pathway will ensure patients are seen faster at the right speciality, diagnosed earlier and treated sooner. Improving the skills mix and enhancing digital connections between primary, secondary and community services in a pathway will reduce unnecessary referrals and encourage treatments closer to or at home
• surgical hubs - increasing surgical productivity will increase efficiency for some of the costliest parts of the NHS. Surgical hubs are separate from a hospital or occupy dedicated space within a hospital in order that they are protected from the pressures in the urgent and emergency care system. This separation of elective procedures with urgent and emergency care, provides the opportunity for patients to be seen and treated faster which will reduce the number of patients on the waiting list faster. Currently 89 elective surgical hubs are operational across England, with a further 56 business cases approved
• expanding community diagnostic centres (CDCs) - the NHS will increase the number of CDCs up to 160 by March 2025. CDCs separate elective diagnostics from acute hospital settings, reducing the risk of COVID infection, and offering improved productivity by reserving facilities for elective care. There are currently 91 operational CDCs that have delivered over 2.4 million additional tests as of November 2022
• making outpatient care more personalised - the NHS will give patients greater control and convenience over their outpatient appointments by supporting them to initiate follow-up care and to self-manage their conditions. This will also reduce the number of unnecessary or low value follow up appointments
• digital productivity programmes - using digital tools such as single sign-on, e-rostering, digital staff passports, improved communication tools, and shared care records to save clinical staff time that can be better spent caring for patients. DHSC will support all trusts to put electronic patient records in place by 2025

Improving productivity and efficiency continues to be important for ensuring that demand growth for health services can be met. The productivity programmes aligned with the elective recovery will build on the achievements of the 2016 Carter Review and the operational productivity programmes which saw a saving of £3.57 billion by January 2020, supporting average productivity growth of 1.6% from 2010 to 2019.

Alongside this, the department and NHSE have created a flexible staffing strategy that aims to meet fluctuations in demand by building a flexible workforce that is sustainable, high quality and value for money for the NHS. A series of measures have been introduced to bring NHS agency spending under control. These measures and the impact they have had on spending are described in chapter 4 of this evidence.

General practice finances

In January 2019, NHSE and the BMA’s GPC agreed a 5-year GP GMS contract framework from 2019 to 2020 to 2023 to 2024. Funding for the core practice contract is therefore agreed and fixed for 2023 to 2024, including for salaried GP pay. As per this agreement between the GPC England, NHS England and DHSC, we are only inviting a recommendation for an uplift to salaried GP pay for 2023 to 2024, and not for GP partners.

The full package of GP contract reform aims to expand the general practice workforce, transforming the system to address workload and retention issues and better meet patient needs. Throughout the COVID-19 pandemic, the government sought to support these ambitions by providing additional funding for increased capacity and introducing measures to support access to general practice and delivery of the COVID-19 vaccination and booster programmes.

In managing uplifts to staff pay from within the fixed GP contract envelope, there are trade-offs for practices, for example between passing on the full uplifts to all staff, expansion of the general practice workforce and contractor GP earnings. Recommendations should therefore be made in line with resources available to practices under the multi-year contract deal and should take account of affordability in the wider economic context.

Investment in general practice

The 5-year GP contract framework implements the commitments set out in the NHS LTP, aimed to transform general practice and is underpinned by a record level of additional investment in primary medical and community care (an extra £4.5 billion by 2023 to 2024). This investment looks to fund demand pressures, workforce expansion, and new services to support growth of more preventative, community-based healthcare and meet the goals set out in the NHS LTP. In 2020, DHSC committed an additional £1.5 billion in cash terms for general practice until 2023 to 2024 for additional staff to deliver the government’s commitments to grow and diversify the general practice workforce. Furthermore, the government made £520 million available to improve access and expand general practice capacity during the COVID-19 pandemic.

Data on investment in general practice for England is published by NHSE. The latest available data is from 2020 to 2021 and a timeseries of investment since 2016 to 2017 is shown in table 2.6 and table 2.7 below. Compared to 2016 to 2017, total spend on general practice services in England by 2020 to 2021 including reimbursement of drugs had increased by 30.9% in cash terms and 16.8% in real terms (2020 to 2021 prices) or 31.4% in cash terms and 17.3% in real terms if excluding reimbursement of drugs.

Table 2.6: investment in general practice in England in real and cash terms excluding reimbursement of drugs dispensed in general practices, A&E streaming and COVID-19 costs, between 2016 to 2017 and 2020 to 2021 (£million)

Year	Excluding reimbursement of drugs, cash terms (£m)	Year-on-year change excluding reimbursement of drugs, cash terms	Excluding reimbursement of drugs, real terms (2020 to 2021 prices, £m)	Year-on-year change excluding reimbursement of drugs, real terms
2016-2017	£9,603.67	-	£10,761.06	-
2017 to 2018	£10,197.97	6.2%	£11,233.52	4.4%
2018 to 2019	£10,535.89	3.3%	£11,383.57	1.3%
2019 to 2020	£11,592.02	10.0%	£12,246.51	7.6%
2020 to 2021	£12,619.58	8.9%	£12,619.58	3.0%

Source: NHS England, Investment in general practice in England, 2016 to 2017 to 2020 to 2021, May 2022, table 1. Real terms figures have been based on unrounded figures.

Table 2.7: investment in general practice in England in real and cash terms including reimbursement of drugs dispensed in general practices and A&E streaming costs and excluding COVID-19 costs, 2016 to 2017 to 2020 to 2021 (£million).

Year	Including reimbursement of drugs, cash terms (£m)	Year-on-year change including reimbursement of drugs, cash terms	Including reimbursement of drugs, real terms (2020 to 2021 prices, £m)	Year-on-year change including reimbursement of drugs, real terms
2016 to 2017	10,193.71	-	11,422.20	-
2017 to 2018	10,879.99	6.7%	11,984.79	4.9%
2018 to 2019	11,237.68	3.3%	12,141.82	1.3%
2019 to 2020	12,319.54	9.6%	13,015.11	7.2%
2020 to 2021	13,345.84	8.3%	13,345.84	2.5%

Source: NHS England, Investment in general practice in England, 2016 to 2017 to 2020 to 2021, May 2022, table 2. Real terms figures have been based on unrounded figures.

Table 2.8: reported investment in general practice in England, 2016 to 2017 to 2020 to 2021 (£ thousands)

	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021
Primary care network participation	-	-	-	104,383	104,975
Clinical negligence scheme for general practice	-	-	-	310,377	312,430
PCO administered funds	470,729	664,705	701,733	995,812	1,089,225
Improving access to general practice	122,771	144,316	237,142	293,137	314,470
Estates and technology transformation programme	136,059	159,508	130,867	137,350	95,959
General practice workforce programmes	47,595	77,328	96,236	116,294	133,088
Other general practice transformation programmes	79,520	129,634	170,523	142,937	163,196
New models of care	13,516	11,433	-	-	-
Primary care network DES	0	0	0	243,016	568,474

Source: NHS England, Investment in General Practice in England, between 2016 to 2017 and 2020 to 2021, May 2022, table 3a.

Dental finances

The total funding for primary care NHS dentistry in 2021 to 2022 was over £3 billion. NHSE are responsible for commissioning primary care dentistry to meet the needs of the local population. £50 million of additional funding for NHS dentistry was made available in January 2022 to be targeted at those most in need of urgent dental treatment, including children. As a result, an additional 64,456 people received care, 67% of which were for urgent care. In July 2022, DHSC and NHSE announced changes to NHS dental contracts, including the introduction of a minimum value of £23 per unit of dental activity (UDA), changes to payments for band 2 treatments, enabling high performing practices to deliver up to 110% of their contracted activity and enabling NHS commissioners to rebase contracts for repeatedly underperforming contracts.

Between June 2020 and July 2022, the government provided over £1.7 billion in income protection to ensure that NHS dentist capacity was retained, and services were provided, throughout the COVID-19 pandemic. NHSE monitored dental activity levels to set contractual arrangements that provide NHS dentists with a reasonable activity threshold to meet. This was designed to take into consideration restrictions on patient throughput as a result of infection prevention and control guidance, whilst still ensuring patient access.

Between April and June 2022, dental practices (excluding orthodontic practices) had to deliver 95% of their contracted activity. Once this threshold was met, dental contractors were reimbursed at 100% of their contract value, minus agreed deductions for variable costs. Financial recovery for undelivered activity was not applied to practices delivering at, or above, the set threshold of dental activity. Further, the rate of financial recovery was then proportionately reduced to a lower threshold value. Beyond the lower threshold, normal financial recovery took place. More information on financial recovery levels is set out in NHSE’s written evidence.

NHSE asked orthodontic practices to return to full delivery of contracted activity from April 2022, and all other dental practices from July 2022. An adjustment to payments to account for the reduction in variable costs associated with face-to-face care not delivered during the COVID-19 remained in place for Q1 of 2022 to 2023. NHSE continued the adjustment made to payment for activity not delivered at 12.75% in the same quarter to further help dental contractors.

NHS dentist income has therefore been largely protected, to ensure practices remain stable through the COVID-19 period, despite the necessary reduction in activity in order to protect patients and staff from infection.

Affordability

In chapters 1 and 2, we have set out the challenging economic and NHS financial landscape for 2023 to 2024, which builds on the difficult position following the 2022 to 2023 pay round.

Against the backdrop of substantial inflationary pressures that are having a widespread impact on the whole economy, it is important that the DDRB understands the impact of pay awards on the SR21 settlement and the commitments made within it. The health and social care system is in a particularly difficult position, with financial pressures most felt due to the prolonged impact of COVID-19, in addition to the wider impact of inflation on budgets. Pay remains the largest component of NHS costs (approximately 65% of total operating costs). Therefore, pay inflation represents a significant cost pressure to be managed. In the context of efficiency requirements that the NHS has committed to deliver as part of SR21, there is a need for strict financial prioritisation of existing budgets.

As previously mentioned in this evidence, the department’s ‘Our plan for patients’ re-committed to improving productivity and delivering the Long Term Plan. The NHS budget prioritises investments that will enable the NHS to support ambulance services more effectively, tackle the elective backlog, establish a strong care sector and make it easier to access primary care.

Through the current financial settlement provided by HM Treasury to the department and reprioritisation decisions, funding is available for pay awards up to 3.5% for the relevant staff groups within DDRB remit this year. Pay awards above this level would require trade-offs for public service delivery or further government borrowing at a time when headroom against fiscal rules is historically low and sustainable public finances are vital in the fight against inflation. Recommendations on salaried GP pay should be informed by affordability and the fixed contract resources available to practices under the 5-year GP contract.

Meeting the DDRB recommendations for 2022 to 2023 had a significant impact on the NHS budget. To put this into context, each additional 1% of pay for the whole Hospital and Community Health Service (HCHS) workforce cost around £900 million for 2022 to 2023, allowing for the full system costs beyond the substantive workforce. The NHS pay recommendations cost £1.4 billion more than was considered affordable. While every effort was made to protect front-line services, and the department went as far as possible in making further efficiencies by looking at all areas of central and corporate spend, meeting the DDRB recommendations in 2022 to 2023 necessitated some tough decisions, including the review of investment in transformation programmes such as reductions to IT transformation funding.

The large size of the NHS workforce compared to other workforces makes the impact of pay pressures correspondingly greater. Pay rises above what has been provisioned will have a material impact on delivery of the government’s commitments and what the NHS has set out to achieve, and further reprioritisation beyond that set out above would be required. NHS budgets are already tight following reprioritisation exercises to fund the ongoing costs of maintaining Living with COVID-19 testing, surveillance and treatment architecture, and the pay deal for 2022 to 2023. As a result, there are a decreasing number of areas where we can look for funding.

These are challenging times for everyone, and our focus is ensuring a fair pay award that recognises the vital importance of public sector workers whilst minimising inflationary pressures and managing the country’s debt.

It is therefore essential that during this challenging fiscal and economic climate, pay remains fair but affordable. We urge the pay review body to carefully consider the important balance between ensuring that existing funding can be used to deliver essential services, prioritising key commitments to improve care, and fairly rewarding staff.

DHSC ministers and officials will be able to provide further information on affordability at oral evidence.

3. Workforce planning, education and training

The NHS in England is staffed by a hugely diverse and dedicated workforce – there are over 1 million people on Agenda for Change contracts, working in over 300 different job roles across acute, mental health and community services. The NHS workforce has grown significantly over recent years, with more people employed by the NHS now than at any time in its history. As of October 2022, there were over 42,000 more staff, including almost 4,700 more doctors and over 10,500 more nurses, compared with a year earlier. The government has completed a 25% increase in medical school places and have made good progress towards delivering 50,000 nurses by the end of this parliament, with over 36,000 more nurses in post in October 2022 compared with September 2019. We have also announced that in 2023 we will publish an independently verified long-term workforce plan, including supply and demand projections.

However, there are challenges, and the workforce remains under pressure. There are high levels of vacancies and leaver rates have increased since April 2021, after having fallen significantly during the COVID-19 pandemic. NHS organisations have increased their use of temporary staff – expenditure on both bank and agency shifts has increased in the past 2 years. Results from the most recent staff survey show that, save for a limited number of measures, staff experience has declined since the previous survey in 2020 (though it is more comparable with earlier years).

Despite pressures, NHS staff have met the challenges of the past few years. Services have continued to transform in order to deliver the care models set out in the NHS LTP, and to meet the new needs generated by the COVID-19 pandemic (such as the vaccination programme). Core NHS services have continued to be delivered. This wouldn’t have been possible without the huge dedication of staff working in every part of the NHS.

Looking to the future, demand for services will continue to grow with demographic and societal shifts. Over the next 15 years, the population of England is projected to increase by 4.2%. The population is also ageing and over the same period the number of people aged over 85 is estimated to grow by 55%. An older population, with different health needs means that the size and shape of the workforce, and the skills that NHS staff have, will need to shift.

The government, working together with NHSE, HEE and partners across the health and care system, is undertaking a large programme of work to train and grow the workforce, recruit internationally and support and retain the current workforce. It is also working to set out, including as part of the long-term workforce plan, the future drivers of demand, to help support the workforce to meet new models of care, and to set out the actions needed to help meet future workforce demand over the long term.

DHSC retains strategic oversight for the health and care workforce and is delivering longer term strategic workforce planning. This includes working closely with NHSE on the plan for elective recovery, which emphasises the importance of workforce in any recovery.

NHSE and HEE have responsibility for shorter term health workforce planning and the deployment of the health workforce to meet service need. Following the passage of the Health and Care Act (2022), each integrated care system (ICS) now has a role in planning workforce requirements for its own service.

The approach NHSE has taken to planning in 2022 to 2023 aligns with the long-term objectives and aims to embed compassionate and inclusive cultures alongside an evidence-based, system-wide approach to workforce planning.

DHSC works through its arm’s length bodies and sector delivery partners on the delivery and implementation of workforce policy. In conjunction with the department, NHSE is responsible for setting the priorities and direction of the NHS workforce and encouraging and informing the national debate to improve healthcare. As part of this work, NHSE is responsible for delivering the NHS People Plan. Education and training of the regulated health workforce in health and social care is the core function of HEE and, subject to parliamentary approval of regulations made under Part 3 of the Health and Care Act (2022), will be merged with NHSE. The merger will help ensure that this workforce is placed at the forefront of the national NHS agenda as it will integrate service, workforce and finance planning in one place, reflecting its importance to NHS delivery. It will also simplify the national system for leading the NHS, ensuring a common purpose and strategic direction.

To support this joint strategic direction DHSC has commissioned NHSE to develop a long-term workforce plan, including long term supply projections. The plan focusses on the practical action the NHS must take, working with partners in government, to grow and transform the workforce, and continue to embed compassionate and inclusive cultures. Guided by a new strategic framework for the health and care workforce, the long-term workforce plan will provide a roadmap that will ensure the NHS has the right number of people, with the right skills, working in the right areas to deliver high quality care. In the Autumn Statement the government committed to publishing the plan in 2023, including independently verified forecasts for the number of doctors, nurses and other key professionals that will be needed in 5, 10 and 15 years’ time, taking full account of improvements in retention and productivity. Combined, these actions will help put the NHS on a sustainable footing over the long-term.

Workforce planning

Growing the workforce

The monthly workforce statistics for October 2022 show that there are record numbers of staff working in the NHS, with over 1.25 million full-time equivalent (FTE) staff (which is over 1.40 million in headcount). Since October 2021, there are now over 19,400 (3.0%) more professionally qualified clinical staff working in NHS trusts and integrated care boards (ICBs), including almost 4,700 (3.7%) more doctors and over 10,500 (3.4%) more nurses. In total there are over 42,000 (3.5%) more hospital and community health service staff (HCHS) compared to October 2021.

We continue to introduce measures to expand the workforce. The government has funded an additional 1,500 undergraduate medical school places each year for domestic students in England - a 25% increase over 3 years. This expansion was completed in September 2020 and has delivered 5 new medical schools in England. In addition, the government lifted the cap on medical and dental school places for students who completed A-levels in 2020 and 2021 and who had an offer from a university in England to study medicine or dentistry, subject to their grades. In addition, funding for up to 200 medical doctor degree apprentices has been confirmed as part of a pilot scheme, making careers in medicine more accessible and helping to boost the number of NHS doctors. The new medical doctor degree apprenticeship aims to provide an alternative route into medicine to deliver a diverse workforce that is more representative of local communities. Following the expansion completed in 2020, there are record numbers of medical students in training in 2022. HEE supports the quality management of undergraduate dentistry clinical placements and provides placement funding across years 2 to 5 of the 5-year degree.

The government has committed to deliver 50,000 more nurses by March 2024. This will be achieved through a combination of investing in and diversifying the training pipeline, recruiting, and retaining more nurses in the NHS. There are already over 36,000 more nurses working in the NHS, since September 2019, as the result of the work of the Nurse 50,000 programme.

To support both the 50,000 Programme and recruitment in general, since September 2020 the government has offered non-repayable grants of at least £5,000 per academic year to all eligible students studying pre-registration programmes across nursing, midwifery and allied health professions. Additional funding is available to students with child dependents (£2,000 p/a) and students studying specialist subjects (£1,000 p/a), alongside reimbursement of travel and accommodation costs and support for exceptional hardship. Through HEE, we have also increased the supply of clinical placements through £55 million of investment in improved capacity.

Retention

Work to support existing staff has been in train since before the COVID-19 pandemic. The pandemic has brought this into sharper focus, and we have worked to help ensure that the existing workforce is well supported and looked after. Retaining NHS staff is a priority and the NHS priorities and operational planning guidance 2022 to 2023 is clear that the wellbeing of the workforce is crucial. The 2020 NHS People Plan sets out a comprehensive range of non-pay actions to improve staff retention. It provides a strong focus on creating a modern, compassionate and inclusive NHS culture by strengthening health and wellbeing, equality and diversity, culture and leadership and flexible working. In addition, the NHS Retention Programme is continuously seeking to understand why staff leave, resulting in targeted interventions to support staff to stay while keeping them well.

National workforce planning

The announcement of the government’s intention to integrate HEE and NHSE is a major step towards unifying workforce planning across the health system so that we are better able to train and recruit the right mix of staff which will maximise the return on our investment. This integration will help ensure that service, workforce, and finance planning are integrated in one place at a national and local level. It will also simplify the national system for leading the NHS, ensuring a common purpose and strategic direction. It is our intention to formalise the integration of HEE and NHSE using the transfer of functions powers contained in the Health and Care Act (2022). Ahead of the exercise of these legal powers, HEE and NHSE will begin to integrate their structures and work. This 2-stage process will help smooth the transition.

HEE has been commissioned to review long term strategic trends for the health and regulated social care workforce and update the existing long term strategic framework for the health workforce. This will help underpin actions which will ensure the system has the right numbers, skills, values and behaviours to deliver world leading clinical services and continued high standards of patient care. For the first time ever, the framework will also include regulated professionals working in social care, like nurses and occupational therapists. This work will look at the key drivers of workforce demand and supply over the longer term and will set out how they may impact upon the required shape of the future workforce, to help identify the main strategic choices.

Building on this work and the work already delivered through the NHS People Plan, DHSC has commissioned NHSE to develop a long-term workforce plan looking at the next 15 years, including supply and demand projections. The government has committed to publishing a comprehensive and independently verified workforce plan in 2023.

Integrated care systems (ICSs) - local workforce planning

ICSs are partnerships of health and care organisations that come together to plan and deliver joined up services and to improve the health of people who live and work in their area, including working to ensure the system is retaining, recruiting and, where required, growing its workforce to meet future need. Each ICS will have an ICB, a statutory organisation bringing the NHS together locally to improve population health and establish shared strategic priorities within the NHS. As we respond to the challenges that the COVID-19 pandemic has placed upon the health and care system, ICBs will have a critical role to play in growing, developing, retaining and supporting the entire health and care workforce locally.

To support them in fulfilling this role, in August 2021, NHSE published draft guidance for ICBs, including specific guidance on the ICS people function. ICBs will have specific responsibilities for delivering against the themes and actions set out in the NHS People Plan, as well as new people requirements outlined in guidance. These include a role for ICBs in growing the workforce for the future and enabling adequate workforce supply, through strategic planning and collaboration across the system to ensure that current and future population, service, and workforce needs are met.

In addition, the draft ICS people function guidance sets out the expectation that ICBs will work with partners within the ICB area to develop system workforce plans for the entire health and care workforce. These should be based on population health needs and taking an integrated planning approach across workforce, finance and activity. The draft guidance also asks ICBs to work with regional and national workforce teams to support aggregated workforce planning and to inform prioritisation of workforce initiatives. In addition to this, the draft guidance also has a focus on the training and development of the current workforce. ICBs are expected to enable staff to learn and work together, as well as flexibly across different parts of the system, whilst developing a consistent system approach to managing talent, supporting social mobility and the potential for lifelong careers across health and care. ICBs will also have a responsibility in ensuring there is accountability for delivering the health and wellbeing agenda across the ICS, including strengthening staff engagement, experience and wellbeing to build workforce resilience across the system.

NHSE will, including through its regional teams, have a role in supporting ICBs to deliver these priorities and responsibilities. Integration requires a workforce equipped with the skills and opportunities to move across the health, public health and social care family, supported by holistic workforce planning to ensure there are the right people to deliver the best outcomes for service users and populations. The Integration White Paper sets out our intention to accelerate workforce integration by removing barriers to collaborative planning and working. Integration will happen at a local level - central government’s role is in facilitating and supporting that, ensuring the right structures, accountability and leadership are in place to enable workforce integration locally.

In 2021, the NHS invested in increasing training places across a number of key service areas - including critical care, learning disability and autism, and mental health. Upskilling staff to work in these settings will mean the NHS can increase capacity to treat patients and improve the quality of services. As these staff complete training, ICSs will need to ensure that their skills are used to best effect.

Additionally, ICSs will play a crucial role in ensuring the action set out in the long-term workforce plan are delivered.

Medical workforce planning

The review into a long-term workforce plan will take into account the drivers behind demand on the medical workforce and supply into the workforce, informing future planning decisions including the commissioning of new medical training places.

The long-term workforce plan commission is collaborative across health bodies, aiming to identify a menu of actions for future workforce scenarios. The plan is currently being developed by NHSE and is expected to report to ministers by the end of 2022. It will build on the work to refresh the strategic framework which collected data from round table discussions, calls for evidence, deliberative events, and literature reviews.

Education and training

DHSC, NHSE and HEE are united in the aim of expanding the health and care workforce, including through ensuring there are diverse routes into healthcare professions to attract a wide range of people and increase social participation. 

Medical school places 

As you are aware, the government has funded an additional  1,500 undergraduate medical school places each year for domestic students in England, completed in September 2020.   

As part of this, 5 new medical schools were opened in Lincoln, Canterbury, Sunderland, Lancashire and Chelmsford. We have seen the first graduates from this expansion enter foundation training in August 2022. Existing medical schools have demonstrated a commitment to sending more trainees to under-doctored areas and increasing the number of GPs and mental health specialists. 

Impact of COVID-19 on undergraduate training

The COVID-19 pandemic caused significant disruption to undergraduate medical education. As a result of the change in the government’s position on A-levels, universities ended up in a position of over-offer of places due to centre assessed grades.  Working closely with HEE, the government found capacity for medical and dental additional training places and ensured all eligible students were offered a place in the 2020 to 2021 and 2021 to 2022 academic years.

Consequently, the government lifted the cap on medical and dental school places in 2020 and 2021. Office for Students data shows that 8,405 medical students entered training in the 2020 to 2021 academic year and initial figures suggest that 8,460 medical students entered training in the 2021 to 2022 academic year, well above the 7,500 cap (Office for Students Medical and Dental Students Survey 2020). We expect to see this increase in places joining the NHS workforce from 2025. This recent growth in medical school places should help build our resilience with more doctors UK trained, helping to reduce reliance on expensive medical agency staff, and ensuring money is better spent on treating more patients. 

The government set out its clear intention that widening participation and reducing gaps in access for students from lower socio-economic backgrounds are central to this medical expansion. The increase will provide more opportunities for people from all backgrounds to study medicine. 

The figure below shows that entrants to medical schools in England by academic year from 2018 to 2019 up to 2022 to 2023 increased. They increased by 11.25% between 2018 to 2019 and 2019 to 2020 following the medical expansion. Entrant figures grew again by 11.1% in academic year 2020 to 2021 taking numbers to the total of 8,405, which was slightly exceeded the following year in 2021 to 2022 as data shows that there were 8,485 entrants.

Figure 3.1: entrants to medical schools in England, by academic year

Source: Office for Students Medical and Dental Students Survey (2019 to 2022)

*NOTE on Figure 3.1: Due to COVID-19 situation and the subsequent changes in A-level grading we saw a higher intake of medical students in the academic year 2020 to 2021 than originally planned.

Distribution of specialty training places

We continue to take steps to improve and streamline postgraduate medical speciality training. In particular, HEE and NHSE are redistributing speciality training places, to ensure that there is an equitable distribution of HEE-funded (through tariff) posts to help address health inequalities across the country. This is major work that will transform the geographical provision of speciality training - aligning posts to where patients and service need them.

The NHS long term plan committed to meaningful action to tackle health inequalities. With this fundamental principle in mind, HEE has worked with NHSE to develop a robust model for guiding the distribution of HEE-funded training posts, being piloted in 3 high-fill specialties (Haematology, Cardiology and Obstetrics and Gynaecology) to better align with patient need. This follows evidence from NHS England showing a correlation between summary hospital mortality Indices and doctors per head of population, together with the realisation that specialty trainees form a crucial component of the junior doctor workforce up until they complete their training.

Medical apprenticeships 

HEE, working with a range of partners have progressed work on developing an apprenticeship in medicine. In July 2022, the Medical Doctor Degree Apprenticeship was approved for delivery by the Institute for Apprenticeships and Technical Education.

Funding for up to 200 medical doctor degree apprentices, has been confirmed as part of a pilot scheme, making careers in medicine more accessible and helping to boost the number of NHS doctors. The new medical doctor degree apprenticeship aims to provide an alternative route into medicine to deliver a diverse workforce that is more representative of local communities.

The medical doctor degree apprenticeship involves the same training, at the same high standard as traditional educational routes. Apprentices will complete all elements of medical education, academic and practical, including a medical degree, the medical licensing assessment and meet all requirements set out by the General Medical Council and will be able to earn a wage while they study.

The apprenticeship has been introduced to make the profession more representative of local communities, so patients are treated by a medical workforce that reflects the diversity of local communities. The aim is to recruit students from varying backgrounds, who may have struggled to pursue a traditional medical degree education, so that future generations of students, and health professionals, more closely mirror the population that they serve. Apprenticeships may also appeal to people who might have gained experience in clinical roles and be ready to start training as a doctor at a later stage in their career. 

This apprenticeship will also enable employers to recruit apprentices as part of their local workforce plans. Apprentices will need to complete their apprenticeship on an approved medical school degree, enabling them to learn and earn and contribute to the NHS. 

Leadership review

Strong leadership across health and social care is an important driver of performance. It is key to building a positive organisational culture and an engaged and motivated workforce which will help ensure high quality care and the efficient and innovative use of public resources.

Leadership for a collaborative and inclusive future review, published June 2022, focusses on the best ways to strengthen leadership and management across health and with its key interfaces with adult social care in England. The report found that ‘a well-led, motivated, valued, collaborative, inclusive, resilient workforce is the key to better patient and health and care outcomes.

The review identified 7 recommendations to foster and replicate the best examples of leadership through improved training, career development and talent management, and through embedding inclusive cultures and behaviours within health and care:

1. targeted interventions on collaborative leadership and organisational values
2. positive equality, diversity and inclusion (EDI) action
3. consistent management standards delivered through accredited training
4. a simplified, standard appraisal system for the NHS
5. a new career and talent management function for managers
6. effective recruitment and development of non-executive directors (NEDs)
7. encouraging top talent into challenged parts of the system

Following a positive reception of the report by the health and care sector, a ‘Review Implementation Office’ (RIO) comprised of stakeholders across DHSC, NHS, social care and local government has been set up to drive forward implementation of recommendations 1 and 2, which are across health and social care. NHSE will lead on delivery of the NHS specific recommendations 3 to 7, working closely with the RIO and the broader health and social care sectors.

Hewitt Review

In the Autumn Budget, the Chancellor announced that there will be an independent review into ICSs (integrated care systems) accountability, targets and performance. The Secretary of State for Health and Social Care has appointed Rt. Hon. Patricia Hewitt to chair this independent review. Patricia Hewitt will bring an immense amount of expertise and knowledge when leading this review. 

As defined in the terms of reference, this review will consider how the oversight and governance of integrated care systems (ICSs) can best enable them to succeed, balancing greater autonomy with robust accountability with a particular focus on real time data shared digitally with DHSC, and on the availability and use of data across the health and care system for transparency and improvement. It will cover ICSs in England and the NHS targets and priorities for which ICBs are accountable, including those set out in the government’s mandate to NHS England. 

In particular, it will consider and make recommendations on: 

• how to empower local leaders to focus on improving outcomes for their populations, giving them greater control while making them more accountable for performance and spending
• the scope and options for a significantly smaller number of national targets for which NHS Integrated Care Boards (ICBs) should both be held accountable and supported to improve by NHS England and other national bodies, alongside local priorities reflecting the particular needs of communities
• how the role of CQC can be enhanced in system oversight

The review will provide recommendations on how we can further empower and enable local leadership to deliver improved outcomes for the populations they serve. The review is currently on-going and recommendations will be delivered in early 2023.

International workforce

Internationally trained staff have been part of the NHS since its inception in 1948 and continues to form a key part of our workforce planning. This government is proud that international health and care workers, including doctors and dentists choose to further their careers and provide world-class care in the NHS.

International recruitment must be done ethically, acknowledging that health and care professionals are globally mobile, and that migration provides opportunities and challenges for the individual, home country and receiving country. DHSC updated its Code of Practice for International Recruitment of Health and Social Care Personnel in August 2022, providing clearer guidance on the scope and application of the code and some ethical issues, for example repayment clauses. As well as, according to the requirements of the code, all recruitment must align with domestic employment legislation.

Throughout this Parliament, we have worked to make sure that health and care staff coming to the UK can do so quickly and easily. The implementation of the health and care visa, which was introduced in August 2020, is open to certain UK health and care roles, including doctors and dentists. Applicants are guaranteed a decision within 3 weeks and the visa fee is substantially reduced compared to standard skilled worker visa costs (from £247 compared to £625). Also, from August 2020 health and social care staff were exempt from paying the Immigration Health Surcharge. 

Since 2016, we have seen increases in joiners of nearly all staff types from the EU and EEA, and all staff groups from Rest of World nationalities. By proportion, 32% (8% EU/EEA, 24% Rest of World) of medical hospital and community health staff have a non-UK nationality (June 2022). While some of these professionals will stay in the UK to further their career, some return to their home countries, taking with them enhanced experience in new clinical settings and new skills.

General practitioners

As explained in last year’s evidence, we are committed to creating an extra 50 million appointments in general practice each year by 2024. To do this, we are taking steps to grow the number of doctors in general practice and diversify the workforce. The recently announced ‘Our plan for patients’ will further improve access to general practice and free up over one million appointments a year.

We recognise the importance of building the future pipeline of GPs trainees, and also retaining the existing expertise within the workforce. However, diversifying the workforce with 26,000 more primary care professionals is also key, and will help to reduce GP workload and deliver more appointments. The department continues to work with NHSE and HEE to boost recruitment, address the reasons why doctors leave or reduce their working hours, and encourage them to return to practice.

We have had record-breaking numbers of doctors accepting places on GP training (4,032 in 2022). There were 2,298 more FTE doctors working in general practice in September 2022 compared to September 2019. The updated GP Contract Framework between 2020 to 2021 and 2023 to 2024 announced a number of new retention schemes alongside continued support for existing schemes for the general practice workforce. An overview of the key schemes was provided in our written evidence to the DDRB for the 2021 to 2022 pay round, including the GP Fellowship Programme, the Supporting Mentors Scheme, the New to Partnership Payment, The GP Retention Scheme and The National GP Induction and Refresher Scheme. Further information on these schemes can be found in chapter 4.

The additional roles reimbursement scheme (ARRS)

To diversify the workforce, the government is working to strengthen existing plans to increase the number of primary care professionals. The 5-year GP contract framework provided funding towards 26,000 additional staff in primary care networks (PCNs) via the additional roles reimbursement scheme (ARRS). The ARRS enables PCNs to recruit a diverse range of professions directly into primary care with the aim of providing a wider range of care options for patients, and multi-disciplinary support according to local needs.

This aims to replicate the model used in hospitals, whereby a consultant leads a multidisciplinary team of professionals. This will help patients to be seen by those who are more expert at dealing with their particular needs, and also help to free up capacity for GPs to focus on what only GPs can do. We also expect this to improve retention of GPs who are increasingly citing high workloads as reasons for reducing their hours or leaving the workforce. Further detail on non-pay factors that affect GP recruitment and retention can be found in chapter 4, including the government’s work to reduce bureaucracy and address the reasons why GPs leave the profession.

Between March 2019 and September 2022, over 21,000 of these professionals have been recruited into general practice. These additional primary care professionals have immediately made an impact, delivering COVID-19 vaccinations and a wider range of services through PCNs, as well as advanced practitioners and professionals in more senior roles anecdotally taking on some GP workload. The 2022 updates to the network contract direct enhanced service in October 2022 increased the number of mental health practitioners available through the scheme and added 2 new reimbursable roles; general practice assistants and digital transformation leads.

Dentists

As set out in ‘Our plan for patients’, we want to make it easier for dentists and dental professionals to work in the NHS.

Dental Education Reform Programme 

HEE continues to implement the Dental Education Reform Programme (DERP) to improve recruitment and retention, in line with their 2021 Advancing Dental Care Review. The review identified ways to improve the use of skill mix of the dental workforce and widen access and participation to training, allowing for more flexible entry routes and developing training places for dental professionals in areas of greatest need.

The DERP aims to improve skills and competencies of dental workforce, improve individual training quality and flexibility in its pathways, improve retention and more effective alignment of workforce to meet local service needs. The 4-year programme established governance, stakeholder engagement and delivery plans in 2021 to 2022 with implementation commencing in 2022.

Key projects in the Dental Education Reform Programme are set out below. HEE will include further detail on these in their evidence:

• procurement and implementation of a Lead Employer model for Dental Foundation Training
• review of Early Years Dental Training established programmes and pilots, with commencement of procurement of new curricula. Early years dental training is a longitudinal programme covering Dental Foundation Training and Dental Core Training Year 1, designed to provide trainees with a wider breadth of experience across sectors within an ICS to enhance skills and knowledge for delivery of dental services
• review of the Dental Therapist Foundation Training education and funding model
• initial development of guided distribution models for Dental Foundation Training and Dental Specialty Training across 3 prioritised specialties - special care dentistry, paediatric dentistry and oral surgery - to inform HEE’s distribution of training investment
• 19 new dental specialty training posts, in the 3 priority specialties, supported to commence in 2022 to 2023

HEE’s Dental Education Reform Programme will seek to address lack of access for patients to specialist dental services within the above dental training distribution workstream. This is pertinent to vital community dental services (CDS) for vulnerable patients with complex health and dental needs. These are local services commissioned by NHS England via a Personal Dental Services agreement in line with local oral health needs assessments. The CDS provide a point of access for Tier 2 complex cases onto specialist paediatric and special care dental pathways, and support the regional referral management systems in conjunction with advice and support to general dental services. The CDS played a key part in the response to the COVID-19 pandemic, standing up as urgent dental centres. They also support valuable oral health promotion and intervention programmes.

The majority of CDS dentists are salaried and managed as NHS Trust employees. Where employed directly by NHS organisations, salaried primary care dentists fall within the HCHS doctor datasets in our evidence. CDS salaried NHS staff have access to the NHS total reward package which is also outlined in our evidence. They have access to a range of benefits on top of their basic salary that are above the statutory minimum and exceed those offered in other sectors.

International dentists 

Overseas dental professionals remain an important part of the NHS workforce and in 2021, 39% of new dentists joining the General Dental Council’s (GDC) register qualified outside the UK.

The department has worked with the GDC on legislative proposals which will allow it greater flexibility to amend its international registration processes and explore alternative registration pathways. Following these legislative changes, which we plan to introduce in 2023, the GDC will consult on draft rules on the future operation of its overseas registration exam (ORE) for dentists, which will enable it to increase the capacity of the assessment. The current legal framework will remain in place for 12 months, following which the regulator will introduce changes to the operation of the assessment. The GDC will also be developing further proposals to make the routes to international registration as a dentist or dental care professional more effective while maintaining the necessary standards for public protection. All future proposals will be subject to approval from the GDC’s Council and public consultation before they are implemented.

Registration data shows that the number of new dentist registrants with an European Economic Area (EEA) qualification has increased - with this group making up 23% of new registrants in 2019, 22% in 2020 and 29.5% in 2021. Following the UK leaving the European Union, current arrangements ensure that UK regulators continue to automatically recognise relevant EEA qualifications of healthcare professionals, including dentists. These arrangements will be reviewed by the government in the first half of 2023.

4. Data on recruitment, retention and motivation

This chapter describes and discusses the existing size of the workforce and how it has changed with regards to patterns of recruitment, retention and motivation. We have highlighted and discussed where there might be COVID-19 impacts as part of sections if apparent. 

There are currently a record and growing number of hospital doctors in the NHS, and the workforce continues to become an ever more diverse workforce in terms of nationality, ethnicity and gender. Education and training pipelines continue to diversify and develop new roles and routes into professions.

However, trends in vacancies, temporary staffing, retention rates and the numbers of staff joining and leaving have been impacted by the COVID-19 pandemic. Leaver rates fell significantly during this period, and these have returned to previous levels for medical staff.

At the end of this chapter we share more information as requested by the DDRB on future workforce supply challenges, including assessments on future levels of international recruitment and how workforce supply is affected by trends and working hours.

Numbers in work - HCHS

The numbers of doctors working in NHS hospital trusts and commissioning bodies continues to increase. The number of Hospital and Community Health Service (HCHS) medical staff has increased by 18,995 (17.5%) full-time equivalents (FTEs) in the period between June 2018 and June 2022. There are though variations in the scale of increases between staff. Consultant numbers have increased by 6,469 (13.9%) but in comparison there have been larger proportionate changes in core training (75.4%) and Specialty Doctors (20.5%).

Table 4.1: number of HCHS doctors as at June each year 2018 to 2022, FTE

The table shows the number of full-time equivalents for each year between June 2018 to June 2022 by staff group

Staff group	June 2018	June 2019	June 2020	June 2021	June 2022	Change since June 2018
Consultant	46,642	48,166	50,243	51,801	53,111	6,469 (13.9%)
Associate Specialist	1,997	1,902	1,919	1,906	2,007	10 (0.5%)
Speciality Doctor	6,777	7,180	7,467	7,898	8,163	1,386 (20.5%)
Staff Grade	310	290	293	309	320	10 (3.2%)
Speciality Registrar	28,973	29,335	30,698	32,350	32,228	3,255 (11.2%)
Core Training	10,096	11,821	13,637	15,401	17,706	7,610 (75.4%)
Foundation Doctor Year 2	6,493	5,539	6,062	6,224	6,334	-159 (-2.5%)
Foundation Doctor Year 1	6,148	6,249	9,322	6,439	6,551	403 (6.6%)
Hospital Practitioner / Clinical Assistant	483	520	529	574	581	98 (20.3%)
Other and Local HCHS Doctor Grades	894	857	821	826	807	-87 (-9.7%)
Grand Total	108,813	111,860	120,990	123,727	127,808	18,995 (17.5%)

Source: NHS Digital HCHS monthly workforce statistics

Doctors are a highly skilled workforce and as part of their professional development and the scope of their work, it is common to take career breaks from the NHS or move between employers. The joiner and leaver data reflects this, for example doctors have a higher annual turnover rate than nurses. This is in part driven by the fact that doctors in training are rotating in and out of hospital settings as part of planned rotations of training and that they are increasingly taking career breaks, although we continue to see the vast majority return to the UK to work in the NHS. Despite the high degree of movement within the workforce, the GMC show low rates of loss over the long term and the workforce is inherently stable. See more information in The state of medical education and practice in the UK: the workforce report 2022, (on page 35, Figure 27, ‘Location of 2016 F2 cohort by UK country after one to 5 years’).

Joiners

The number of joiners to the medical workforce has grown by 26% since the year 2016 to 2017. While the number of joiners reflects the higher degree of mobility and rotation of the workforce as well as its increasing size, it is important to note the increases in joiners coming from international recruitment. (See section on international workforce)

Joiner rates are the percentage of the HCHS workforce joining their staff group each year. For medical staff, there isn’t much variation in joiner rates between regions. Joiner rates are steadily growing in all regions up until the year to June 2020. There was a noticeable drop in joiner rates in all regions in the year to June 2021 driven by COVID-19, but they have increased since. The joiner rates in all regions vary between 17.3% and 18.9% in the year to June 2022 as shown in Table 4.2.

Table 4.2: annual rates of HCHS doctors joining active service by region, years to June 2017 to June 2022

NHSE name	June 2016 to June 2017	June 2017 to June 2018	June 2018 to June 2019	June 2019 to June 2020	June 2020 to June 2021	June 2021 to June 2022
All NHSE regions	17.3%	17.1%	18.5%	21.2%	16.1%	18.1%
London	17.6%	17.7%	18.0%	19.7%	16.2%	18.0%
South West	17.7%	17.2%	18.9%	21.7%	15.4%	18.4%
South East	17.1%	17.7%	18.6%	21.4%	16.2%	18.2%
Midlands	16.9%	17.0%	19.1%	21.6%	17.6%	18.4%
East of England	20.1%	18.2%	19.6%	21.9%	17.3%	18.9%
North West	16.2%	15.9%	18.2%	21.8%	16.1%	17.4%
North East and Yorkshire	16.2%	16.3%	17.7%	21.5%	13.8%	17.3%

Source: NHS Digital HCHS monthly workforce statistics

Leaver rates and trends

The leaver rate for HCHS medical staff has remained stable over the last 10 years, as shown in Figure 4.1, except for a drop in 2019 to 2020 during the COVID-19 pandemic.

The leaver rate is the percentage of the workforce leaving their staff group in NHS trusts and ICBs in a year. It excludes staff moving between trusts but includes movement of doctors from trusts to other settings such as general practices, this is important as doctors in training may often leave trusts to work in other settings or countries during their training. When excluding doctors in training medical staff leaver rates are below other non-medical staff groups (Figure 4.3). NHS Digital produces turnover statistics based on information in the NHS Electronic Staff Record.

The annual rate of medical staff leaving active service was 14.7% for the year to 2011 to 2012. Over the last 10 years, the leaver rate peaked at 15.8% in 2015 to 2016 and reached a low of 13.7% in 2020 to 2021, as likely more people hesitated to leave during the COVID-19 pandemic. Data for 2021 to 2022 shows leaver rates for all staff and nurses are now returning to pre-COVID-19 levels. For context, a thousand additional/fewer doctors leaving the NHS equates to about a 0.8% change in the leaver rate.

Figure 4.1: annual HCHS rates of staff leaving active service in the group by staff group, between 2011 to 2012 and 2021 to 2022

Source: NHS Digital HCHS monthly workforce statistics

Over time, HCHS medical staff leaver rates have varied between 12% to 17% across regions. There is though not a large degree of variation between rates in regions.

Table 4.3: annual rate of medical staff leaving active service in hospital and community health service settings by region, years to June 2016 to June 2022

NHSE Region	June 2016 to June 2017	June 2017 to June 2018	June 2018 to June 2019	June 2019 to June 2020	June 2020 to June 2021	June 2021 to June 2022
All NHSE regions	14.5%	14.5%	15.7%	13.8%	13.7%	14.8%
London	15.4%	15.2%	15.4%	13.9%	13.6%	14.7%
South West	14.3%	15.0%	16.1%	14.4%	14.6%	15.2%
South East	15.2%	14.7%	16.9%	13.9%	13.1%	14.3%
Midlands	14.2%	14.3%	14.9%	15.1%	13.6%	14.8%
East of England	12.9%	14.3%	15.4%	12.9%	13.9%	15.1%
North West	14.2%	14.2%	16.6%	13.5%	14.5%	15.0%
North East and Yorkshire	14.5%	14.0%	15.3%	12.8%	13.1%	14.7%

Source: NHS Digital HCHS monthly workforce statistics

While the leaver rate varies between the different specialties, they appear to be broadly consistent over a number of years within a speciality area. Differences between specialities are likely in part to reflect the differing levels of doctors in training (who are more likely to rotate out of the HCHS setting represented in a specified period).

Figure 4.2 below highlights the impact of COVID-19 on annual joiners, with increased numbers in the year to June 2020 as graduating doctors joined the service early and the corresponding dip in the year to June 2021. Figure 4.4 also shows leaver rates for HCHS Doctors have remained steady since June 2010. The graph shows the higher level of joiners which is driving continued increases in the total number of doctors in post.

Figure 4.2: annual joiner and leaver rates from active service for HCHS doctors, years to June 2010 to June 2022

Source: NHS Digital HCHS monthly workforce statistics

GP workforce data

As the department highlighted to the DDRB last year, we recognise the need to increase the GP workforce and workload continues to be primary factor in morale and retention of the workforce. This circular relationship underpins our efforts to expand and diversify the general practice workforce, and trends in workforce data can provide useful insight.

Data on the general practice workforce is published by NHS Digital. General practice workforce numbers are subject to seasonal variation, linked to recruitment and training cycles each year: they historically reach an annual high in September, as the next cohort of GP trainees start training, followed by a gradual decline over the rest of the year. Comparisons looking at long term trends in capacity, therefore, should only be made with the same annual time point, for example, September to September.

Table 4.4 and 4.5 present a summary of doctors by role type working in general practice by headcount and full-time equivalent, since 2017. As of September 2022 there were a total of 37,026 full time equivalent (FTE) doctors in general practice in England (46,283 headcount).

Table 4.4: doctors in general practice in England, FTE, by role, September 2017 to September 2022

Practitioner type	Sept 2017	Sept 2018	Sept 2019	Sept 2020	Sept 2021	Sept 2022
All doctors in general practice	34,637	34,369	34,729	35,393	36,495	37,026
GP partners	20,195	19,293	18,462	17,641	17,059	16,750
Salaried GPs	7,629	8,115	8,496	9,133	9,752	9,865
GPs in training grade	5,508	5,880	6,547	7,454	8,576	9,470
GP retainers	88	121	186	228	254	252
GP regular locums	1,216	960	1,037	937	854	689

Source: NHS Digital, general practice workforce, 30 September 2022, October 2022, table 1a. Methodological changes were introduced in December 2021 and the back series has been revised. Data includes estimates for practices that did not provide fully valid staff records.

Table 4.5: doctors in general practice in England, headcount, by role, September 2017 to September 2022

Practitioner type	Sept 2017	Sept 2018	Sept 2019	Sept 2020	Sept 2021	Sept 2022
All doctors in general practice	42,355	42,343	43,442	44,617	45,980	46,283
GP partners	22,777	21,856	21,100	20,363	19,876	19,537
Salaried GPs	11,457	12,315	13,109	14,257	15,267	15,433
GPs in training grade	5,646	5,986	6,686	7,558	8,664	9,628
GP retainers	213	315	485	576	640	618
GP regular locums	3,027	2,469	2,532	2,297	2,117	1,668

Source: NHS Digital, general practice workforce, 30 September 2022, October 2022, table 1b. Methodological changes were introduced in December 2021 and the back series has been revised. Data includes estimates for practices that did not provide fully valid staff records

Overall, the general practice workforce data show the number of doctors in general practice grew by 2,298 FTE from September 2019 to September 2022, an increase of 6.6% (2,841 or 6.5% increase by headcount). This is driven by promising growth among salaried GPs and doctors in GP training. However, the number of FTE GP contractors continued to decline from September 2021 to September 2022. While this means there has been an overall loss in the number of FTE qualified permanent GPs, excluding regular locums and those in training grade, (277 fewer FTE compared to September 2019), the number of headcount qualified permanent GPs has increased over the same period (a headcount increase of 843). This is due in part to differences in working patterns between partner and salaried GPs (see participation rates and part-time working in Tables 4.6 and 4.7). A number of policy programmes are being undertaken to boost retention and increase participation, as outlined in the section on GP retention below.

Demographics of the GP workforce

The demographic makeup of the workforce by job role and gender has not changed since previous years. As at September 2022, there were more female doctors in general practice (19,479 FTE - 53%) than male (17,291 FTE - 47%); however, more males continue to work as GP partners and locums. GP trainees now make up a larger proportion of the workforce in September 2022 (25.6%) compared to September 2021 (23.6%).

Age and gender distribution also varies with role. Salaried GPs and doctors in GP training make up a higher proportion of the younger workforce, female doctors make up a higher proportion of GPs under 45 and a higher proportion of male GPs in older age bands. Differences in working patterns (see participation rates and part-time working in tables 4.7 and 4.8) between male and female workers are likely to impact workforce trends in FTE by role.

Table 4.6: doctors in general practice, FTE, by job role and gender, September 2022

Practitioner type	All	% of all GPs by type	Male	% of all male GPs by type	Female	% of all female GPs by type
GP partners	16,750	45.2%	9,687	56.0%	6,916	35.5%
Salaried GPs	9,865	26.6%	3,013	17.4%	6,755	34.7%
GPs in training grade	9,470	25.6%	4,167	24.1%	5,299	27.2%
GP retainers	252	0.7%	55	0.3%	195	1.0%
GP regular locums	689	1.9%	369	2.1%	314	1.6%

Source: NHS Digital, general practice workforce, 30 September 2022, October 2022, table 1a. Data includes estimates for practices that did not provide fully valid staff records. Excludes doctors whose gender was unknown.

GP part-time working and participation rates

Participation rates are used to measure the extent of part-time working in the GP workforce. They are defined as the ratio of full-time equivalents to headcount. Participation rates as of September 2022 are shown by role and gender in table 4.6, by age and gender in table 4.8 and by role since September 2017 in table 4.9. A full-time working week is considered to be 37.5 hours.

Participation rates are lower for female GPs in each job role and in every age band. Contractor GPs and GPs in training have the highest participation rates regardless of gender; regular locums and retainers have the lowest. GPs in training grade participation rates appear to be higher as a trainee’s full-time contract is 40 hours, compared to the standard full time salaried and/or contractor GP contract which is 37.5 hours. Overall, participation rates are broadly similar to last year, and table 21 shows how this changed between 2017 and 2022.

Table 4.7: participation rates of doctors in general practice by gender and job role, September 2022 (%)

Practitioner type	Male	Female	All (including unknown)
All doctors in general practice	88.7	73.7	80.0
GP partners	92.7	77.6	85.7
Salaried GPs	69.6	61.7	63.9
GPs in training grade	103.2	94.9	98.4
GP retainers	48.7	39.0	40.8
GP regular locums	43.7	38.8	41.3

Source: NHS Digital, General Practice Workforce, 30 September 2022, October 2022, tables 1a and 1b. Data includes estimates for practices that did not provide fully valid staff records. 

Table 4.8: participation rates of doctors in general practice by age and gender, September 2022 (%)

Age band	Male	Female	All (including unknown)
All	88.7	73.7	80.0
Under 30	105.7	102.2	103.6
30-34	90.5	80.2	84.1
35-39	84.6	70.0	75.2
40-44	87.2	67.7	75.0
45-49	90.1	68.7	77.6
50-54	90.0	70.2	79.1
55-59	89.8	71.3	80.7
60-64	81.1	68.4	76.5
65 and over	77.6	70.2	75.7
Unknown	73.8	63.7	70.6

Source: NHS Digital, general practice workforce, 30 September 2022, October 2022, tables 2a and 2b. Data includes estimates for practices that did not provide fully valid staff records.

Table 4.9: doctors in general practice, participation rates, by role, September 2017 to September 2022 (%)

Staff group	Sept 2017	Sept 2018	Sept 2019	Sept 2020	Sept 2021	Sept 2022
All doctors in general practice	81.8	81.2	79.9	79.3	79.4	80.0
GP partners	88.7	88.3	87.5	86.6	85.8	85.7
Salaried GPs	66.6	65.9	64.8	64.1	63.9	63.9
GPs in training grade	97.6	98.2	97.9	98.6	99.0	98.4
GP retainers	41.4	38.3	38.4	39.6	39.7	40.8
GP regular locums	40.2	38.9	41.0	40.8	40.4	41.3

Source: NHS Digital, general practice workforce, 30 September 2022, October 2022, tables 1a and 1b. Methodological changes were introduced in December 2021 and the back series has been revised. Data includes estimates for practices that did not provide fully valid staff records.

GP locums

While many locum GPs work for practices on a long-term or regular basis, for example maternity cover or a regular weekly or monthly session, ‘ad-hoc’ locums are those who work on a less regularised basis, such as covering sessions at short notice.

As part of the methodological changes implemented in the June 2021 publication to facilitate the move to monthly practice workforce reporting, ad hoc locum GP figures were removed from the main publication and instead included in an annex. Figures for ad-hoc locums are collected and calculated differently to the rest of the general practice workforce which includes regular locums, in that they represent ad-hoc locum use across the whole quarter, rather than a snapshot of the general practice workforce.

The number of regular locums, as of 30 September 2022 was 689 FTE (1,668 headcount). There were an additional 288 FTE ad hoc locums working in general practice during September 2022 (1,451 headcount). This was 126 FTE fewer ad-hoc locums working in general practice compared to September 2021 (650 fewer headcount). 341 ad-hoc locums worked in another general practice role during the reporting period, 264 fewer than in September 2021.

Other primary care staff

As mentioned above, we are also taking steps to diversify the workforce in general practice. Growing the general practice workforce with 26,000 more primary care professionals, including clinical pharmacists, social prescribers, physiotherapists and dieticians, will mean bigger teams of staff providing a wider range of care options for patients. The 5-year GP contract seeks to address workload pressures and provide full reimbursement of additional staff in PCNs via the ARRS.

To complement the general practice level workforce data, since March 2020, NHS Digital have separately published quarterly statistics on the workforce in PCNs, which are labelled as ‘experimental’. As of September 2022, there were 4,235more FTE direct patient care staff, such as physiotherapists, social prescribers and pharmacists working in general practice compared to March 2019. Additionally, as of September 2022, 12,721 FTE direct patient care staff have been employed in PCNs since March 2020 when data was first collected, though due to data quality issues, this is likely to be an underestimation.

Table 4.10: all staff working in general practice, FTE, September 2017 to September 2022

Staff group	Sept 2017	Sept 2018	Sept 2019	Sept 2020	Sept 2021	Sept 2022
All staff	125,467	128,107	131,370	133,663	138,372	143,126
All staff excluding doctors	90,830	93,739	96,641	98,270	101,877	106,099
Doctors	34,637	34,369	34,729	35,393	36,495	37,026
Nurses	15,976	16,310	16,530	16,635	16,510	16,779
Other direct patient care staff	10,311	11,161	12,154	13,148	14,519	15,754
Admin/non-clinical	64,543	66,268	67,957	68,487	70,848	73,567

Source: Source: NHS Digital, General Practice Workforce, 30 September 2022, October 2022, table 1a. Methodological changes were introduced in December 2021 and the back series has been revised. Data includes estimates for practices that did not provide fully valid staff records.

Table 4.11: direct patient care staff employed in primary care networks, FTE, September 2020 to September 2022

Staff group	Sept 2020	Sept 2021	Sept 2022
Other direct patient care staff	1,880	7,420	12,721

Source: NHS Digital, Primary Care Network Workforce, 30 September 2022, October 2022, table 1a. Data does not include estimates for primary care networks that did not provide fully valid staff records, or for records with no contracted or worked hours recorded.

Table 4.12: all staff working in general practice, headcount, September 2017 to September 2022

Staff group	Sept 2017	Sept 2018	Sept 2019	Sept 2020	Sept 2021	Sept 2022
All staff	173,625	176,365	180,924	183,234	188,476	192,011
All staff excluding doctors	131,293	134,050	137,506	138,654	142,565	145,800
Doctors	42,355	42,343	43,442	44,617	45,980	46,283
Nurses	23,064	23,419	23,773	23,807	23,554	23,490
Other direct patient care staff	15,747	16,625	17,874	18,994	20,712	21,840
Admin/non-clinical	92,879	94,390	96,181	96,190	98,690	100,958

Source: NHS Digital, general practice workforce, 30 September 2022, October 2022, table 1b. Methodological changes were introduced in December 2021 and the back series has been revised. Data includes estimates for practices that did not provide fully valid staff records

Dental workforce data

NHSE is responsible for commissioning NHS primary care dental services from providers to meet local dental needs in England. Providers are individuals or corporate bodies who hold a contract with the NHS. NHS dentists can be either performer only (also known as associates), who subcontract with or are employed by dental contract holders to deliver NHS dentistry, or provider-performers (contract holders who perform NHS dentistry). Dentists can also offer private care alongside NHS services.

Figures on the number of dentists who have delivered NHS dentistry in any given financial year are shown in Table 4.13.

Table 4.13: number of dentists with NHS activity by dentist type, between the year 2007 to 2008 and 2021 to 2022

Year	Total	Providing-Performer	Performer only/associates
2007 to 2008	20,815	7,286	13,529
2010 to 2011	22,799	5,858	16,941
2011 to 2012	22,920	5,099	17,821
2012 to 2013	23,201	4,649	18,552
2013 to 2014	23,723	4,413	19,310
2014 to 2015	23,947	4,038	19,909
2015 to 2016	24,089	3,449	20,640
2016 to 2017	24,007	2,925	21,082
2017 to 2018	24,308	2,555	21,753
2018 to 2019*	24,545	4,954	19,550
2019 to 2020*	24,684	4,863	19,781
2020 to 2021*	23,733	4,682	19,026
2021 to 2022*	24,272	4,752	19,485

Source: NHS Dental Statistics for England - 2021 to 2022 Annual Report - NHS Digital

*Note on table 4.12: methodology changed in these years, figures are not comparable to earlier years. They refer to England only. There was a small number of dentists in these years where it was unknown whether they were a providing-performer or associate.

From 2020 to 2021 up to 2021 to 2022 the total number of dentists actively delivering NHS services increased from 23,733 to 24,272 (2.3% increase). We understand that the DDRB requested information on the numbers of dentists working as providing-performers. From 2020 to 2021 up to 2021 to 2022, both the number of providing-performers and the number of performer only (or ‘associate’) dentists rose, bringing the total number closer to pre-COVID-19 levels. This follows from a fall the previous year, which we think is linked to the COVID-19 pandemic when activity was reduced in line with Infection Prevention and Control advice. A new methodology for determining dentist type implemented for 2018 to 2019 onward resulted in many dentists being reclassified as providing-performer. There are now 4 years of comparable data.

The percentage of dentists (undertaking NHS activity submitted by FP17 forms to NHS BSA detailing dental activity data) who are female has increased from 43.5% in 2010 to 2011 to 52.6% in 2021 to 2022. This is a continuing trend of slight increases each year. There are more female dentists than male dentists aged 35 and under (59.9%) and aged between 35 and 44 (57.6%). However, male dentists disproportionately represent those aged 55 and above, making up 69.6% of dentists in this age group.

Figures for the number of NHS dentists by age are shown in table 4.14. There was an increase across all age groups in 2021 to 2022 except in the under 35 category, where there was a slight decrease. We understand that the DDRB requested information on average retirement age. We do not hold this information; however we know how many dentists are in the 55+ age group and are therefore the closest group to potential retirement age. There has been a 1.2% increase in the proportion of dentists aged over 55 between 2011 to 2012 and 2021 to 2022 from 13.5% to 14.7%, an increase of 482 dentists in this age group. There has also been a fall in the proportion of dentists aged under 35 from 37.3% in 2011 to 2012 to 36.0%, although the overall number of dentists in this age group has increased by 186 over the time period.

Table 4.14: number of dentists with NHS activity by age group, from 2011 to 2012 up to 2021 to 2022

Year	Under 35	35-44	45-54	55+	Total dentists
2011 to 2012	37.3%	26.3%	22.9%	13.5%	22,920
2012 to 2013	37.0%	26.7%	22.5%	13.7%	23,201
2013 to 2014	36.5%	27.4%	22.1%	14.1%	23,723
2014 to 2015	36.2%	27.9%	21.4%	14.5%	23,947
2015 to 2016	36.3%	28.0%	21.3%	14.4%	24,089
2016 to 2017	36.2%	28.1%	21.2%	14.5%	24,007
2017 to 2018	36.5%	28.3%	20.7%	14.5%	24,308
2018 to 2019	36.5%	28.7%	20.2%	14.7%	24,545
2019 to 2020	36.5%	28.7%	20.2%	14.6%	24,684
2020 to 2021	36.3%	28.7%	20.6%	14.4%	23,733
2021 to 2022	36.0%	28.7%	20.6%	14.7%	24,272

Source: NHS dental statistics for England - 2021 to 2022 annual report - NHS Digital

In 2020 to 2021 there were 1,398 joiners and 1,414 leavers for NHS dentistry. Table 4.16 shows the net difference between the number of joiners and leavers between 2011 to 2012 and 2021 to 2022. Since 2012 to 2013 there has been net increase for GDS dentists, other than in 2019 to 2020 where the number of leavers increased by 577 (+42%) compared to 2018 to 2019, whilst the number of joiners stayed comparatively stable (increased by 35 (+2%) compared to 2018 to 2019).

Table 4.15: number of dentists with NHS activity by contract type, and overall net difference between joiners and leavers, from 2012 to 2013 up to 2020 to 2021

Year	Number of NHS dentists by contract type				Total number of NHS dentists	Net change (joiners - leavers)
	GDS	Mixed	PDS	TDS
2011 to 2012	17,834	1,826	2,151	1,109	22,920	-
2012 to 2013	18,447	1,812	1,924	1,018	23,201	475
2013 to 2014	19,133	1,814	1,877	899	23,723	300
2014 to 2015	19,625	1,658	1,799	865	23,947	160
2015 to 2016	19,976	1,543	1,709	861	24,089	17
2016 to 2017	20,046	1,542	1,625	794	24,007	27
2017 to 2018	20,514	1,446	1,536	812	24,308	305
2018 to 2019	20,915	1,342	1,501	787	24,545	86
2019 to 2020	21,062	1,381	1,462	779	24,684	-543
2020 to 2021	20,124	1,430	1,474	705	23,733	-16
2021 to 2022	20,303	1,735	1,602	632	24,272	-

Source: NHS dental statistics for England - 2021 to 2022 annual report - NHS Digital

We understand that the DDRB requested trends in recruitment and retention in community dental services (CDS) and personal dental services (PDS). DHSC does not hold this information. As commissioners of PDS arrangements (including CDS), NHSE are better placed to provide information on vacancies, supply of dentists and status of contracts. The CDS are discussed in chapter 3 on workforce in terms of training places.

International workforce

Internationally trained staff numbers continue to grow and make up about a third of the medical workforce.

Table 4.16: proportion of medical hospital and community health service staff by staff grade and nationality, headcount, June 2022

Staff Group	EU/EEA	Rest of World	United Kingdom	Unknown
HCHS Doctors	8.1%	24.0%	66.3%	1.7%
Consultant	8.8%	12.0%	77.2%	2.1%
Associate Specialist	7.8%	26.6%	62.3%	3.4%
Specialty Doctor	9.0%	43.1%	45.7%	2.3%
Staff Grade	14.1%	45.9%	35.2%	4.8%
Specialty Registrar	7.7%	30.7%	61.0%	0.6%
Core Training	7.5%	45.0%	45.9%	1.5%
Foundation Doctor Year 2	6.7%	23.6%	68.4%	1.3%
Foundation Doctor Year 1	6.4%	14.7%	76.9%	2.1%
Hospital Practitioner / Clinical Assistant	3.8%	4.9%	88.5%	3.1%
Other and Local HCHS Doctor Grades	4.8%	6.1%	86.6%	2.6%

Source: NHS Digital - [NHS Hospital and Community Health Service (HCHS) Workforce Statistics](https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics

We have seen the impact of the policies described in chapter 3, in growth in international staff - shown in increased proportion of medical professionals with a non-UK nationality between 2016 and 2022.

Table 4.17: proportion of all medical hospital and community health service staff who Have a non-UK Nationality by grade, headcount, June 2016 to June 2022

Doctor grade	June 2016	June 2017	June 2018	June 2019	June 2020	June 2021	June 2022
HCHS doctors	24%	25%	26%	27%	28%	30%	32%
Consultant	20%	20%	20%	20%	20%	20%	21%
Associate specialist	28%	28%	28%	28%	30%	32%	34%
Specialty doctor	45%	46%	46%	47%	48%	50%	52%
Staff grade	43%	48%	44%	42%	50%	56%	60%
Specialty tegistrar	30%	30%	30%	32%	34%	36%	38%
Core training	30%	32%	36%	42%	45%	48%	53%
Foundation doctor year 2	17%	18%	20%	24%	25%	28%	30%
Foundation doctor year 1	14%	16%	16%	16%	15%	18%	21%
Hospital practitioner / clinical assistant	9%	7%	7%	7%	7%	7%	8%
Other and local HCHS doctor grades	10%	11%	12%	10%	9%	10%	11%

Source: NHS Digital - NHS hospital and community health service (HCHS) workforce statistics

In January 2021, the UK introduced a new points-based immigration system to replace free movement from the EU. This system is global, meaning overseas recruits face the same immigration control whether they come from the EU or further afield. Set against an overall increase in medical workforce headcount since 2016, we have seen a small proportional reduction in headcount from EU/EEA medical staff, but a significant proportional increase in Rest of the World medical staff.

Source: NHS Digital - NHS hospital and community health service (HCHS) workforce statistics

The ethical recruitment of health and care staff from overseas is vital. We updated our code of practice for international recruitment on 2 August 2022 in line with latest advice from the World Health Organisation (WHO). This guarantees the most stringent ethical standards when recruiting health and social care staff from overseas and prohibits active recruitment from those countries that the WHO identifies as having the most vulnerable health systems (also known as ‘red list’ countries). Red list countries where we have a bilateral agreement are categorised as ‘amber list’ - and all recruitment must be undertaken in line with the agreement.

While we are concerned about the increase in migration of health and care workers from countries on the red list, this must be balanced against an individual’s right to migrate, which is also supported by WHO guidance, domestic employment and equalities law.

Table 4.18: medical joiners to NHS trusts and other core organisations in England by top 10 nationalities, headcount, year to June 2022

Nationality Group	Listing	Headcount	Proportion of all Staff
British	N/a	13,037	53.9%
Indian	Green	1,794	7.4%
Pakistani	Red	1,197	4.9%
Nigerian	Red	1,075	4.4%
Egyptian	Green	837	3.5%
Unknown	N/a	374	1.5%
Irish	Green	339	1.4%
Sri Lankan	Green	337	1.4%
Malaysian	Green	323	1.3%
Sudanese	Red	316	1.3%

Source: NHS Digital - NHS hospital and community health service (HCHS) workforce statistics

International registration process for dentists

Overseas dental professionals remain an important part of the NHS workforce and in 2021, 39% of new dentists joining the register were from overseas. As set out in our July 2022 package of improvements, we want to make it easier for people to work for, and support the NHS. As part of this, we will review the current NHS systems that authorise dentists to work for the NHS and will be streamlining routes into NHS dentistry for those trained overseas so they can start treating patients more quickly.

Registration data shows that the number of new registrants coming from the EEA has increased - 23% of applicants in 2019, 22% in 2020 and 29.5% in 2021. Following the UK leaving the European Union, current arrangements ensure that UK regulators continue to automatically recognise relevant healthcare qualifications (including dentists) from the European Economic Area (EEA). These arrangements will be reviewed by the government in the first half of 2023.

Retention

HCHS reasons for leaving

Reasons for leaving are collected within ESR and provide an insight for some aspects of staffing motivation. Any conclusions drawn from this need to be mindful of a continually increasing rate of an ‘unknown’ reason being recorded; up to over 45% of total reasons for leaving by 2021 to 2022. We have noted the requests for the past few years for more information in this area, but we are limited to the data captured within the ESR system. Consideration of the burden on the health system of any changes to current data collection are key in this area and the department has no current plans to seek an expansion of the data collected.

The most commonly specified reason for leaving is staff reaching the end of a fixed term contract, making up 18% of total reasons for leaving in 2021 to 2022. However, this is linked to doctors in training grades rotating between training posts. The number of voluntary resignations has increased for 2021 to 2022 and is higher than recent previous years. Among those leaving voluntarily the most common reasons are relocation, promotion and work life balance, it is not though possible to determine the specific impact of COVID-19 within this.

There is no obvious impact of the COVID-19 pandemic on patterns of reasons given for leaving, and specifically no obvious impact on the numbers retiring.

The General Medical Council found that over half of doctors who have left the Register (55%) are still working clinically abroad, while around a quarter of doctors are likely to return (24%), however, the majority (59%) say they are both unlikely and unwilling to return.

Of those who are likely to return, just 10% are currently in the UK, while the remaining 90% are currently abroad, the vast majority of whom are currently working clinically (93%).

In the ‘Completing the picture survey’, the GMC found the reasons for leaving are very varied with a mix of more ‘neutral’ reasons, such as returning to their country of previous residence (32%) and retiring (26.8%), and more negative reasons, such as burnout (27.2%) and dissatisfaction (35.7%). Other less common reasons are also noteworthy, including bullying (5.5%) and harassment (3.1%).

Table 4.19: HCHS doctors, reasons for leaving, 2016 to 2017 to 2021 to 2022

Reason for leaving	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Dismissal	68 (0.4%)	68 (0.4%)	71 (0.4%)	53 (0.3%)	56 (0.3%)	62 (0.3%)
Employee transfer	171 (1.1%)	164 (1.0%)	673 (3.7%)	195 (1.1%)	245 (1.4%)	261 (1.3%)
End of fixed term contract	4,028 (25.1%)	3,835 (23.2%)	4,148 (22.5%)	3,457 (19.7%)	3,144 (18.3%)	3,594 (18.3%)
End of fixed term contract - completion of training scheme	989 (6.2%)	876 (5.3%)	993 (5.4%)	853 (4.9%)	657 (3.8%)	761 (3.9%)
End of fixed term contract - end of work requirement	216 (1.3%)	198 (1.2%)	218 (1.2%)	197 (1.1%)	175 (1.0%)	194 (1.0%)
End of fixed term contract - external rotation	1,685 (10.5%)	1,497 (9.1%)	1,259 (6.8%)	1,188 (6.8%)	1,070 (6.2%)	1,201 (6.1%)
End of fixed term contract - other	414 (2.6%)	401 (2.4%)	324 (1.8%)	353 (2.0%)	381 (2.2%)	466 (2.4%)
Mutually agreed resignation	9 (0.1%)	6 ( 0.0%)	3 (0.0%)	3 (0.0%)	9 (0.1%)	3 (0.0%)
Others	63 (0.4%)	46 (0.3%)	47 (0.3%)	63 (0.4%)	96 (0.6%)	62 (0.3%)
Redundancy	31 (0.2%)	26 (0.2%)	34 (0.2%)	26 (0.1%)	22 (0.1%)	11 (0.1%)
Retirement	903 (5.6%)	927 (5.6%)	914 (5.0%)	917 (5.2%)	995 (5.8%)	1,095 (5.6%)
Voluntary resignation	2,846 (17.7%)	2,893 (17.5%)	2,686 (14.6%)	2,751 (15.7%)	2,531 (14.7%)	3,226 (16.5%)
Unknown	4,630 (28.8%)	5,587 (33.8%)	7,052 (38.3%)	7,475 (42.6%)	7,791 (45.4%)	8,662 (44.2%)
All reasons for leaving	68 (0.4%)	68 (0.4%)	71 (0.4%)	53 (0.3%)	56 (0.3%)	62 (0.3%)

Source: NHS Digital HCHS monthly workforce statistics. Note: totals may not equal the sum of the total

HCHS vacancies

There are multiple measures for vacancies which NHS Digital collate as an experimental statistics release. As part of that series, NHSE undertake a monthly workforce data collection from NHS trusts, which includes data on staff in post (including bank and agency) and vacancies (defined as the difference between the reported whole-time equivalent substantive staff in post and planned workforce levels). This is the considered the best available measure presently and represents the variance between the reported whole-time equivalent (WTE) substantive staff in post and planned workforce levels.

The vacancy rate for medical staff has shown large variation over the last 4 years, ranging from 4.8% to 9.0%, which is equivalent to vacancies of over 6,600 to over 11,600 as shown in Table 4.20. The recorded rate is increasing post COVID-19 but has not yet reached the levels seen in other staffing groups. NHS Digital report that the drop in vacancy rates over 2020 and 2021 is in part due to the impact of COVID-19 on the ability of trusts to complete comprehensive workforce planning during the COVID-19 pandemic. The increase in vacancy rates in 2022 is likely to be in part this effect unwinding.

Vacancies should reflect the headroom for sickness absence, maternity leave and temporary staffing which a trust is expecting to require. Bank and agency staff are used to cover some vacancies, in addition to covering sickness absence and long term leave.

Table 4.20: HCHS doctor vacancies and vacancy rates, June 2019 to June 2022

Medical staff	Vacancy rate	WTE vacancies
2019 to 2020 Q1 (June 2019)	9.0%	11,630
2019 to 2020 Q2 (September 2019)	7.0%	9,247
2019 to 2020 Q3 (December 2019)	6.7%	8,876
2019 to 2020 Q4 (March 2020)	6.3%	8,338
2020 to 2021 Q1 (June 2020)	6.0%	8,075
2020 to 2021 Q2 (September 2020)	5.3%	7,262
2020 to 2021 Q3 (December 2020)	5.1%	6,954
2020 to 2021 Q4 (March 2021)	4.8%	6,634
2021 to 2022 Q1 (June 2021)	7.0%	9,659
2021 to 2022 Q2 (September 2021)	5.6%	7,855
2021 to 2022 Q3 (December 2021)	5.8%	8,254
2021 to 2022 Q4 (March 2022)	5.6%	8,016
2022 to 2023 Q1 (June 2022)	7.3%	10,582

Source: NHS Digital HCHS monthly workforce statistics

GP recruitment

Growing the future pipeline of trainees is critical to increasing the number of doctors in general practice. To boost recruitment, we have increased the number of GP training places. Increasing the number of GP trainees will help to ease workloads and increase capacity in practices, allowing more patients to get the care they need. Just as in hospitals, trainees provide direct patient care whilst being safely supervised and supported. The highest ever number of doctors accepted a place on GP training last year; 4,000 trainees. Table 4.2 shows the growth in the number of GP training places available and accepted since 2017.

Further to this, the GP training model continues to undergo reform to support better training for GPs and a more balanced distribution of trainee capacity across the NHS. GP trainees have traditionally spent around half of their 3-year training working in general practice, but this proportion is increasing to 2 years in general practice placements, through a phased approach. This is helping to better prepare trainees for a role in general practice.

Recent data from the GP Speciality Training dashboard (source TIS) shows that 2,464 doctors achieved a Certificate of Completion of Training (CCT) as a GP in the 2021 to 2022 academic year, the majority of whom would have commenced training in 2018 to 2019 when 3,473 spaces were available. This highlights the importance of ensuring that trainees are supported to achieve their CCT, to maximise the number that take on a substantive role in general practice post-training.

There are schemes in place to attract more doctors to GP speciality training including the ‘choose GP’ advertising campaign and the targeted enhanced recruitment scheme (TERS) which started in 2016. TERS is a national incentive scheme that funds a £20,000 salary supplement to attract trainee GPs to work in areas of the country where training places have been unfilled for a number of years. Since 2016, the scheme has widened its criteria to include under-doctored and deprived areas. Additional government investment has seen the number of places on the scheme expand to 550 in 2021 to 2022 and this has grown to 800 places in 2022 to 2023.

Table 4.21: general practice speciality training places available, accepted and fill rate

GP speciality training	2017	2018	2019	2020	2021	2022
Places available	3,250	3,250	3,250	3,750	4,000	TBA
Acceptances	3,157	3,473	3,540	3,793	4,001	TBA
Fill rate	97%	107%	109%	101%	100%	TBA

Source: Health Education England, General Practice ST1 Recruitment Figures

GP retention

The 2020 updated GP contract framework announced a number of new retention schemes alongside continued support for existing schemes for the general practice workforce. Work continues on targeted efforts to retain GPs in the workforce. These include the GP fellowship programme, the supporting mentors scheme, the new to partnership payment (which had supported 2,000 GPs to take up partnership positions by September 2022), The GP retention scheme and the GP return to practice programmes (formerly combined with the GP international induction programme to form the national GP induction and refresher scheme).

Older GPs leaving the profession

We understand that early retirements are a key factor impacting GP retention and know that the annual and lifetime allowances for tax free pension saving can trigger GP retirement decisions for those that hit the thresholds. Individuals are encouraged to seek independent financial advice as it could remain in GPs’ interests to stay in the profession when they hit their lifetime allowance.

‘Our plan for patients’ set out a package of NHS Pension Scheme measures to help retain doctors, nurses and other experienced NHS staff - including GPs. We recently launched a consultation that sets out proposals for partial retirement which helps staff to work more flexibly up to and beyond retirement age, and changes to scheme rules to protect NHS staff from unintentionally higher annual allowance charges driven by inflation. Removing the 16-hour rule permanently and allowing returning retired staff to build up a second pension will help facilitate future retire and return. Whilst not just for GPs, these measures will support existing GPs to continue contributing their expertise for longer and incentivise those who have retired to return to practice.

We are also working with NHS England to ensure that NHS employers are able to offer the option of recycling unused employer pension contributions into pay for staff who opt-out of the pension scheme because they have exceeded their pension tax allowances. As independent contractors, GP partnerships are able to set up their own contribution recycling arrangement for their partner and salaried GPs should they wish.

We also know that pension annual and lifetime allowances are not the only drivers for early retirements. The 2021 GP work-life survey reported that increasing workloads were the most considerable job stressor amongst GPs surveyed, and we continue to work with the NHS to understand how we can help GPs and improve their working environment.

According to analysis of NHS pensions scheme membership, of the GPs taking their 1995 Section pension (all reasons), the proportion doing so on a voluntary early retirement (VER) basis increased from 19.9% in 2008 to a peak of 51.5% in 2017. The proportion taking VER has dropped slightly since but has remained high at 40.1% in 2022. Table 4.22 contains further detail on the number of GPs taking their pension.

However, this is not a measure of retirement, but a measure of GPs taking their pension and anecdotally, we know that some GPs will take their pension and return to the workforce (retire and return). We do not have robust data on the number of GPs that take their pension and remain in the workforce, and if they do stay in the workforce, in what capacity this is, including job role.

It is important to note that the data below is not comparable to the previous GP pensions dataset shared in the 2022 to 2023 DDRB evidence. More information on this can be found in chapter 7.

Table 4.22: the number of GPs taking their pension (NHS Business Services Authority analysis of 1995 pensions scheme membership)

Pension Year Ending (1 April to 31 March)	Number of GPs in total claiming NHS pensions*	Total number of GPs** claiming VER pensions	% taking VER
2008	1126	224	19.9
2009	1235	245	19.8
2010	1412	301	21.3
2011	1238	363	29.3
2012	1231	464	37.7
2013	1105	425	38.5
2014	1451	714	49.2
2015	1142	529	46.3
2016	865	397	45.9
2017	1192	614	51.5
2018	1011	450	44.5
2019	1044	473	45.3
2020	1017	433	42.6
2021	943	387	41.0
2022	683	274	40.1

Source: NHS Business Services Authority analysis of the number of GPs taking their pension (1995 pension scheme only).

*Includes all types of NHS pensions awarded to GPs (age, VER and ill-health). **There will be a very small number of ophthalmic medical practitioners included.

HCHS diversity analysis

The NHS hospital and community health service medical workforce is significantly more ethnically diverse than those employed across the UK economy. Across the medical workforce, approximately 46% of the workforce is white, while 5% are black or Black British and 29% are Asian or Asian British. There are currently around 8% of the workforce with unknown or not stated ethnicity.

Table 4.23: hospital and community health service doctor ethnicity by medical grade, June 2022

June 2022 (Headcount)	Asian or Asian British	Black or black British	Chinese	Mixed	White	Any other ethnic group	Not stated	Unknown and discontinued codes
All grades	29.5%	5.5%	2.5%	3.6%	46.1%	5.0%	6.0%	1.8%
Consultant	28.3%	2.9%	2.2%	2.5%	54.5%	3.7%	4.9%	1.0%
Associate specialist	40.3%	4.8%	0.8%	3.3%	36.6%	6.9%	5.6%	1.8%
Specialty doctor	40.7%	7.6%	0.8%	3.6%	31.4%	8.1%	6.2%	1.6%
Staff grade	35.5%	7.6%	2.0%	4.5%	29.0%	9.9%	8.2%	3.4%
Specialty registrar	27.9%	7.5%	3.1%	4.5%	42.5%	5.6%	6.6%	2.3%
Core training	31.4%	9.0%	2.8%	4.8%	35.4%	6.9%	6.7%	2.9%
Foundation doctor year 2	28.3%	6.1%	3.7%	4.2%	42.0%	4.4%	7.9%	3.5%
Foundation doctor year 1	26.8%	5.2%	4.5%	4.7%	45.2%	4.2%	6.9%	2.6%
Hospital practitioner / clinical assistant	19.1%	2.4%	0.8%	1.5%	62.9%	1.8%	8.8%	2.7%
Other and local HCHS doctor grades	23.7%	2.9%	1.9%	2.1%	59.2%	1.8%	6.6%	1.8%

Source: NHS Digital HCHS monthly workforce statistics

The overall representation in the workforce of staff with non-white ethnicity has been slowly increasing since 2016. Doctors in training grades have seen the largest change in non-white ethnicity representation since 2016.

Figure 4.3: proportion of staff reporting non-white ethnicity by medical grade, September 2016 to June 2022

Source: NHS Digital HCHS monthly workforce statistics

Gender balance in the medical workforce

Data from June 2022 shows that just under 46% of the medical workforce are female. The proportion of female staff varies by grade with higher proportions of female staff at foundation year 1 (57%), foundation year 2 (57%) and speciality registrar (51%). The overall proportion of female staff has slightly increased over the past 6 years (45% to 46%), but the increase has been larger where they were previously underrepresented, with the proportion of consultant who are female rising from 35% to 39%.

Table 4.24: gender by medical grade, June 2022

Staff group	Female	Male
All doctor grades	46.0%	54.0%
Consultant	39.1%	60.9%
Associate specialist	40.0%	60.0%
Specialty doctor	46.1%	53.9%
Staff grade	42.0%	58.0%
Specialty registrar	51.3%	48.7%
Core training	48.5%	51.5%
Foundation doctor year 2	56.8%	43.2%
Foundation doctor year 1	57.0%	43.0%
Hospital practitioner / clinical assistant	51.0%	49.0%
Other and local HCHS doctor grades	68.1%	31.9%

Source: NHS Digital HCHS monthly workforce statistics

Figure 4.4: gender breakdown by HCHS medical grades, 2016 and 2022

Source: NHS Digital HCHS monthly workforce statistics

Temporary staffing

A temporary workforce market allows the NHS to meet demand fluctuations without the need to increase capacity above that which would be required on a sustained basis. Trusts use their own banks (managed in-house or via management companies) and external agencies to resource extra temporary staff.

The NHS is experiencing a period of unprecedented demand so providers may need to use temporary staff.   

Measures were introduced in 2015 to curb NHS agency spending including price caps, the mandatory use of approved frameworks for procurement, and the requirement for all trusts to stay within the specified annual expenditure ceilings for agency staff.

The measures, which are regularly monitored for compliance and effectiveness, aim to reduce costs and give greater assurance on quality.

The department and NHSE’s flexible staffing strategy aims to support NHS providers to reduce their agency staff bills and encourage workers back into substantive and bank roles. Trusts are encouraged to develop and improve their strategy, procurement and commercial negotiation in their approach to temporary staffing. There are 3 workstreams:

• off-framework: work in partnership with trusts, systems and our approved framework operators to reduce or eliminate off-framework supply into the NHS in order to give assurance on quality and value for money standards of the staff working via agencies
• price cap compliance: continue to implement and monitor the agency Rules with ongoing collection and analysis of data and working with ICSs and trusts to support intervention where necessary
• bank acceleration programme: develop and deliver the Bank Programme and measure and report key programme outcomes. Increase the number of collaborative banks in England to reduce the reliance on agency by offering increased flexibility to bank staff. Increase transparency and collaborative working within the NHS to reduce competitive behaviours
• NHS England has re-established measures in September 2022 to control agency expenditure, including a system agency expenditure limit. Metrics used to monitor performance on agency usage are included in the NHS oversight framework, which reinforce the rules that NHS trusts and FTs should comply with

Insights into medical and dental staff group

Doctors who choose to work through agencies cite flexibility, relatively higher pay, improved support systems, culture and a smaller admin burden as the main reasons for doing so. This is opposed to those who choose to work substantive shifts, who tend to cite involvement in teaching and research; learning and development; and predictable pay and hours. For bank shifts, pay and the ability to take control over the time, duration and place of shifts are the biggest attractions.

Price cap compliance

Trusts are required to procure agency staff via approved frameworks and within price caps, unless there are exceptional circumstances (known as ‘break glass’). Price cap compliance for all staff groups has remained constant at 60% since 2018; However, for the medical and dental staff group compliance has typically been around 14% to 2020 to 2021. The national shortages of medics in certain specialities (such as orthopaedics, geriatrics, cardiothoracic oncology and radiology) may contribute to poorer compliance rates amongst this group. This causes greater variability in hourly rates between on and off-framework spending.

Trends in temporary staffing

The ‘agency rules’ have contributed to a reduction in spending on agency workers to £2.4 billion in 2020 to 2021 compared to £3.6 billion in 2015-2016. Agency spend in 2020 to 2021 accounted for 4.0% of the overall NHS paybill, down from 7.8% at its peak in 2015 to 2016.

Bank spend increased significantly from £3.8 billion in 2019 to 2020 to £4.67 billion in 2020 to 2021 and spend on both agency and bank increased further in 2021 to 2022. Demand for temporary staff has been high in response to the workforce pressures and the reinstatement of healthcare services since the COVID-19 pandemic. It is expected that demand for temporary staffing will remain high in 2022 to 2023.

Higher temporary staffing costs are being driven by both volume effects (more shifts) and price pressures. These are related because higher demand for staff generates a supply shortfall and will result in some price inflation. When the growth in labour supply does not keep up with increasing demand, temporary staff are used to cover substantive vacancies.

Staff engagement and wellbeing

The NHS staff survey gives useful information about many aspects of staff experience at work.

The most recent NHS staff survey was undertaken in November 2021 and published in March 2022. The results were aligned to the 7 themes of the NHS people promise in 2021, replacing the old themes except for staff engagement and morale. As a result of this change, it is no longer possible to provide a year-on-year comparison with the previous theme scores except for staff engagement and morale. However, the individual questions have largely remained the same, and comparisons with previous years can be made.

The results of the 2021 NHS staff survey have seen a decline on many measures, including thinking there are sufficient staff, satisfaction with pay, morale, stress, and the number of people thinking about leaving. Staff engagement has decreased from 7.0 in 2020 to 6.8 in 2021 and is at the lowest level seen in the last 5 years.

Perhaps unsurprisingly, given the pressure of the COVID-19 pandemic, the survey suggests a picture of a system under sustained pressure which is impacting on staff’s experience of working in the NHS.

While the context helps to explain the 2021 results, considerable work through the NHS People Promise has been undertaken to support staff wellbeing, create a compassionate and inclusive culture and leadership, and promote flexible working opportunities. NHS England is leading a programme of work to grow and strengthen occupational health services across the NHS.

‘We work flexibly’ is one element of the People Promise. Becoming a more flexible, modern employer will help to recruit and retain people more effectively. NHS staff now have a day one right to request flexible working in the NHS Terms and Conditions.

In addition to national investment in specialist mental health and wellbeing support, NHS organisations now have wellbeing guardians, a role that supports boards in creating an organisational culture that prioritises the health and wellbeing needs of staff. Line managers have been given training to support them to facilitate wellbeing conversations with staff.

In addition, the NHS national health and wellbeing team are now working with systems who are piloting tailored, locally owned health and wellbeing offers to suit the needs of their workforce.

Many of these programmes of work are focused on creating a sustainable long -term cultural shift and impact will not be seen immediately; they require time and sustained investment. Within the current challenging context that NHS staff are operating it is vital that this support continues to ensure that they feel supported and have a positive experience of working within the NHS.

Satisfaction with pay

Medical staff satisfaction with pay is higher than for other sections of the workforce with around 50% of all medical staff reporting they are either satisfied or very satisfied with pay. Satisfaction tends to correlate with earnings with satisfaction being higher for consultants (60%) compared to doctors in training (35%). While there were falls in satisfaction with pay in 2021 compared to the previous year, over the longer term satisfaction for consultants is broadly similar to what it was in 2017. For doctors in training the level of satisfaction was down from 47% the previous year and the lowest since 2017.

Sickness absence - HCHS

For the year to June 2022 the absence rate for medical staff was 1.82% which compares to 5.38% across all staff groups. The rate of sickness absence had been stable over the past decade, with rates between 1.16% and 1.29% until 2019 to 2020. Increases in recent years are due to the impact of the COVID-19 pandemic. Data is available for the HCHS sector only (not for primary care).

Table 4.25: HCHS doctor sickness absence rates, between 2010 to 2011 and 2021 to 2022

Year	Sickness Absence Rate (%)
2010 to 2011	1.16%
2011 to 2012	1.19%
2012 to 2013	1.25%
2013 to 2014	1.22%
2014 to 2015	1.21%
2015 to 2016	1.23%
2016 to 2017	1.25%
2017 to 2018	1.29%
2018 to 2019	1.29%
2019 to 2020	1.49%
2020 to 2021	1.65%
2021 to 2022	1.82%

Source: NHS Digital HCHS monthly workforce statistics

For the last 6 years, data is also available by grade. In general, changes in individual grades’ rates of absence have followed the pattern for the medical workforce as a whole. Where changes have been larger (for example, the hospital practitioner grade) these tend to be the staff groups with the smallest staff numbers (though doctors in training grades and consultants do have lower rates than SAS doctors).

Table 4.26: sickness absence rates by medical grade, between 2016 to 2017 and 2021 to 2022

Grade	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
HCHS doctors	1.25%	1.29%	1.29%	1.49%	1.65%	1.82%
Consultant	1.18%	1.24%	1.24%	1.40%	1.54%	1.63%
Associate Specialist	2.38%	2.88%	2.50%	2.79%	3.07%	2.69%
Specialty Doctor	2.08%	2.11%	2.05%	2.37%	2.61%	2.61%
Staff Grade	4.44%	3.37%	3.47%	1.97%	1.68%	2.68%
Specialty Registrar	1.15%	1.19%	1.20%	1.44%	1.57%	1.83%
Core Training	1.14%	1.09%	1.10%	1.38%	1.56%	1.79%
Foundation Doctor Year 2	0.98%	0.99%	1.12%	1.22%	1.47%	1.81%
Foundation Doctor Year 1	0.95%	0.97%	1.02%	1.25%	1.72%	1.97%
Hospital Practitioner / Clinical Assistant	1.52%	1.38%	2.65%	2.69%	1.00%	1.76%
Other and Local HCHS Doctor Grades	1.99%	2.20%	2.05%	2.25%	1.95%	2.21%

Source: NHS Digital HCHS monthly workforce statistics

Over the past 4 years, sickness absence rates have generally been higher for medical staff in the North West and North East and Yorkshire compared to medical staff in London, as shown in Table 4.26. This pattern is the same as that seen for non-medical staff.

Table 4.27: HCHS doctors sickness absence rates by region, between financial years 2018 to 2019 and 2021 to 2022

Region	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
England	1.3%	1.5%	1.6%	1.8%
London	0.9%	1.1%	1.6%	1.4%
South West	1.4%	1.6%	1.6%	1.9%
South East	1.2%	1.4%	1.6%	1.8%
Midlands	1.5%	1.6%	1.6%	1.8%
East of England	1.3%	1.5%	1.6%	1.7%
North West	1.5%	1.7%	1.6%	2.1%
North East and Yorkshire	1.5%	1.6%	1.6%	2.2%

Source: NHS Digital HCHS monthly workforce statistics

COVID-19 related sickness absence

NHS Digital data is available to describe trends in sickness absence during the response to COVID-19. Additional coding has been made available on the ESR for organisations to record against. This data will not though track staff absence for non-sickness reasons.

Figure 4.5 shows the ESR reported rates of sickness absence for medical staff split by those coded as COVID related or not. The underlying rate of non-covid absence is currently above that seen in the baseline year of 2018-19 and will be monitored going forward.

Figure 4.5: monthly COVID and Non-COVID sickness absence rates for medical staff, March 2020 to May 2022

Source: NHS Digital HCHS monthly workforce statistics

GP wellbeing and morale

The national GP worklife survey is a regular series of studies, commissioned by the department and carried out by the University of Manchester, that focuses on GPs’ experiences of their working lives, including job satisfaction, sources of pressure and job attributes. The 11th survey was published in April 2022 and ran between December 2020 and December 2021. The results from the survey showed that:

• the mean level of overall satisfaction rates decreased significantly from 4.49 to 4.3 (on a scale from 1-7) between 2019 and 2021). Overall satisfaction has reduced to a level similar to 2015
• the pressure experienced as a result of common job stressors all decreased but varying amounts, however these all remain high, with increasing workloads the most common stressor. More than 8 out of 10 GPs reported experiencing considerable or high pressure from increasing workloads and increased demands from patients
• average working hours worked in a week reported by GPs surveyed in 2021 was 38.4 hours, a notable decrease of 1.6 hours from 2019. When compared to average participation rates detailed in Table 5.14, this suggests that some GPs are working more than their contracted hours of those surveyed, over a third (33.4%) of GPs said there was a considerable or high likelihood of them leaving ‘direct patient care’ within 5 years. For GPs under 50, the ‘intention to quit’ is at its highest level compared to previous surveys. However, the percentage of GPs over 50 who expressed this is lower than 2019 and its lowest level since 2015

In 2020, the government committed to jointly reviewing bureaucracy in general practice, alongside NHSE, with the intention of reducing the burden on GPs and teams by releasing more time for case. Since then, we have made several changes to reduce unnecessary bureaucracy for GPs to free up time for appointments, including expanding the range of healthcare professionals who can sign fit notes. Additionally, in August 2022 the government published the bureaucracy busting concordat; 7 principles to reduce unnecessary burdens. The concordat signals to the sector the government’s commitment to adhere to the principles of reducing bureaucracy, to allow GPs and primary care teams more time to focus on the high-quality care they already provide to patients every day.

The provision of mental health services, such as NHSE and RCGP’s #LookingAfterYouToo and the #LookingAfterYourTeam, is important for building resilience and reducing burnout in general practice. These coaching support services provide access to mental health services to all primary care workers, managers and leaders employed or contracted to deliver work on behalf of the NHS and aim to encourage psychological wellbeing and resilience in teams.

Additional DDRB requests

The DDRB asked for more information on future workforce supply challenges, including assessments on future levels of international recruitment and how workforce supply is affected by trends and working hours.

Since 2018 the number of doctors joining the UK workforce with a non-UK primary medical qualification (PMQ) has exceeded the number with a UK PMQ. Except for 2020 the number grew each year from 2018 to 2021 when it reached over 13,000 non-UK joiners.

Figure 4.6: doctors taking up (or returning to) a licence to practise

Source: The state of medical education and practice in the UK: The workforce report 2022, GMC.

The scale of demand for international recruitment in England will vary by grade. Non-UK graduates made up around 30% of doctors recruited to specialist training posts in England in 2021. The proportion is expected to fall when the 1,500 medical school expansion of 2018 to 2020 start to enter core, GP, or run-through training from 2025. Over 1,000 international graduate doctors are likely to be required to fill the current number of specialty training posts despite the 1,500 medical school expansion.

Future demand for international recruitment to other doctor grades is harder to estimate because recruitment choices are made by individual NHS trusts. International supply will vary by specialty and grade. Demand for future international recruitment depends on the leaver rate of existing UK and international recruits. The leaver rates of EEA and international medical graduates are much higher than UK graduates.

‘Almost 9 in 10 (89%) of the UK graduates who first took up a licence to practise in 2015 were still licensed in 2021 but this was only the case for two thirds (66%) of international medical graduates (IMGs) and under half (47%) of the European Economic Area (EEA) graduates who joined that year.’ GMC Workforce Report 2022

As the number of overseas doctors in the NHS workforce grows, the need for further international recruitment may also grow to replace the losses from the high turnover.

International recruitment in the longer term

Modelling from the WHO’s global strategy on human resources for health projects a shortfall of 750,000 doctors across OECD countries by 2030. Although there is some uncertainty in this projection, strong competition is likely to remain in the global doctor labour market.

In the longer term, developing nations that currently provide doctors to other countries may see economic growth combined with higher healthcare demands from their older populations. This may increase competition for doctors and change the geographic profile of countries the OECD attracts international recruits from.

To help ensure the NHS has the workforce it needs for the future the government has commissioned NHS England to develop a long term workforce plan looking at the next 15 years, building on the work delivered through the People Plan.

This plan will help ensure that we have the right numbers of staff, with the right skills to transform and deliver high quality services fit for the future.

The high-level long term workforce plan will look at the mix and number of staff required across all parts of the country and will set out the actions and reforms that will be needed to reduce supply gaps and improve retention.

The plan is currently being developed by NHS England. The government has committed to publishing a comprehensive workforce plan in 2023 and this will include independently verified forecasts for the number of doctors, nurses and other professionals that will be needed in 5, 10 and 15 years’ time, taking full account of improvements in retention and productivity.

Trends in average working hours

NHS Digital data shows doctors continue to work close to full time on average. The overall HCHS doctor participation rate (the ratio of FTE to headcount) has remained at 94% over the decade to 2022. The participation rate of trainees has fallen slightly over the past ten years, down 1% point for core trainees and specialist registrars. It has increased for associate specialists (+1% point) and specialty doctors (+4% points). The trend for consultants is a slight fall, down 1% point over the decade.

Figure 4.7: average participation rates for HCHS doctor grades

In 2019, women doctors averaged 91% of full time, men 96% of full time. This is in part due to women choosing to work part-time following maternity leave. It is common for mothers to work part-time after returning from maternity leave, on average contracted hours drop to 85% of full time for doctors/dentists. Fewer than 2 in 5 work full-time 2 years after going on maternity leave, compared to 94% 4 years before maternity leave IFS Maternity and the labour supply of NHS doctors and nurses.

The IFS also found levels of part-time working vary by specialty. The higher the proportion of men in a specialty the less likely women are to go on maternity leave, and they return on higher hours if they do so. Conversely, in many female dominated specialties the impact of maternity on FTE is larger. These differences may result from different attitudes to flexibly across specialties, or from the characteristics of doctors that choose different specialities. The rate of change towards more part-time working will depend not only on the proportion of women in the workforce, but whether these variations by specialty change.

The long-term trend has been a greater proportion of women entering medical school. This has led to more women in training grades. It is expected there will be a trend towards more part-time working in the senior doctor grades as more women move into these grades.

In August 2022 HEE introduced more flexibility to work less than full time for a period in foundation training and for all specialty training specialties. This may lead to increased part-time working.

The trend in part-time working will mean more doctors are required to provide the same level of FTE in future. The impact of flexibility from part-time working in all grades may also lead to increased retention, which will help boost supply and counter the reduced hours worked. The impact of less than full-time working on retention is not yet known.

5. Earnings and expenses

It is important that the NHS pay offer can effectively recruit and retain the staff that it needs across the full range of roles and seniority. Similarly, the pay system should ensure that all staff are rewarded fairly for the service they deliver and have the opportunities and incentives to progress and develop in their chosen line of work. As such, the competitiveness of the NHS reward package for both existing staff and potential new recruits is an important consideration when setting pay rates.

This chapter includes information on the pay and earnings for doctors and dentists in England and covers staff working in the HCHS, general practice and the dental sector. This covers junior doctors, SAS doctors, consultants, independent contractor GPs, salaried GPs, providing performing and associate general dental practitioners (GDPs) and salaried GDPs working across a range of NHS settings.

This chapter will include information on:

• information on latest pay and earnings in the HCHS sector covering junior doctors, SAS doctors and consultants and discussion of some of the key factors influencing those changes
• information on latest pay and earnings for the GP workforce
• information on latest pay and earnings for the dental practitioner workforce
• information on the latest comparisons of pay and earnings between the medical workforce, the wider economy, and other high-income professions

For 2022 to 2023, the government accepted the recommendations of the DDRB in full which increased basic pay by 4.5% for the staff groups within the DDRB remit that year which we expect to feed into data over the coming year.

In 2021 to 2022, average pay and earnings for doctors working in the HCHS sector increased by slightly over 3% which was consistent with the outcome of the 2021 to 2022 pay round and existing multi-year agreements.

For GPs, the latest data available is from 2020 to 2021, which shows average earnings increased by 2% for salaried GPs and 16.6% for GP partners. The outcome of the 2020 to 2021 pay round was a 2.8% uplift to salaried GP pay scales. GP earnings data for 2021 to 2022 will be published in 2023.

In 2023 to 2024 there remain some groups with existing multi-year pay agreements:

• this is the third, and final, year of the multi-year agreement with SAS doctors on the new 2021 contracts
• contractor GPs are subject to a 5-year agreement between the BMA and NHSE, (however recommendations are being sought on uplifts to the minimum and maximum of salaried GP pay scales). 2023 to 2024 will be the final year of the 5-year agreement

Medical staff are highly paid individuals with a legitimate expectation of a salary towards the upper end of the UK wage distribution with average earnings for HCHS doctors in the top 5% of the wage distribution following a clear path of career advancement as they develop competence in their specialty and progress to more senior grades.

The relative position of medical staff in the UK wage distribution has been relatively constant over time and we believe that the 2022 to 2023 pay award was broadly in line with pay settlements across the wider economy.

We expect that the DDRB will want to consider the latest available data and developments in the wider economy and labour market when making its recommendation. We welcome the opportunity to give our views on the emerging situation and what that might mean for pay policy in oral evidence.

Hospital and community health sector earnings

Average pay and earnings in 2021 to 2022

FTE basic pay for medical staff working in the HCHS Sector in England range from £29,384 for foundation Year 1 to £119,133 for the most experienced consultants. On top of this medical staff can access additional earnings linked to additional activity and excellence awards.

NHS Digital publish information on average pay and earnings for the HCHS workforce split by career grade. There are 3 principal measures that can be used depending on the context:

• total earnings per person - this is the average level of earnings across the group and includes all pay elements including basic pay, additional activity and clinical impact awards. This measure is not available on a ‘per FTE’ basis as it cannot be assumed that earnings increase in direct proportion with FTE.
• total basic pay per FTE - This is the average level of basic pay across the group if it assumed that all staff were working full time. It is possible to calculate this measure because basic pay increases directly with working time.
• total basic pay per person - This is the average amount of basic pay received with no adjustment for FTE and will therefore be lower than the ‘per FTE’ measure. This measure does not include any additional pay element such as additional activity or impact awards

Table 5.1 shows average pay and earnings for the HCHS sector for the 12-months to March 2022 and can be used to assess change for the whole workforce, and specific career grades, over the past year. Doctors in the new ‘specialty doctor’ contract are in the ‘specialty doctor’ grade and those in the new ‘specialist doctor’ contract are in the ‘associate specialist’ career grade.

Table 5.1: average pay and earnings for the HCHS sector for the 12-months to March 2022 and a comparison to the previous year

	Average FTE	Basic pay per FTE	Basic pay per FTE growth	Total earnings per person	Total earnings per person growth
HCHS doctors	126,325	£70,921	3.1%	£85,245	3.1%
Consultant	52,291	£101,049	3.1%	£122,449	3.8%
Associate specialist	1,861	£91,868	2.9%	£98,544	5.8%
Specialty doctor	8,013	£69,003	3.1%	£73,198	5.0%
Staff Grade	317	£61,163	0.2%	£71,506	5.8%
Specialty registrar	32,990	£47,291	3.4%	£61,553	0.9%
Core training	16,500	£42,283	3.2%	£55,141	1.6%
Foundation doctor Year 2	6,249	£33,089	2.2%	£42,910	-0.5%
Foundation doctor Year 1	6,694	£28,653	2.1%	£36,364	2.8%
Hospital practitioner / Clinical assistant	580	£121,075	1.8%	£42,923	7.3%
Other and local HCHS doctor grades	830	£96,774	5.7%	£57,013	2.5%

Source: NHS Digital earnings statistics

Between April 2021 and March 2022, average basic pay per FTE and average total earnings per person both increased by 3.1% across the entire HCHS workforce.

The growth in pay and earnings varies somewhat between staff groups which will, in part, reflect some of the differences between contracts over the period:

• for the consultant workforce average basic pay increased by 3.1% which is broadly in line with the pay award of 3%. Total earnings grew by 3.8% which may be linked to an increase in additional earnings this year
• for SAS Doctors in the Associate Specialist and Specialty Doctor grades basic pay grew by around 3% which is consistent with the pay award and the impacts of the new SAS contracts. Average earnings increased by more which may reflect some of the changes in the new SAS contract that came into operation from April 2021
• for junior doctors the increase in basic pay per FTE was consistent with what would have been expected under the 2018 agreement with increases of around 2% in the foundation grades and higher in the specialty registrar grades with larger increases for the most senior doctors in nodal point 5. Growth in average earnings for these doctors was lower than basic pay although we note this may include the effects of continuing transition to the new contract, which shifted earnings from additional earnings (banding supplements) to basic pay, and the disruptive effect of the COVID-19 pandemic on working patterns

The data provided runs to the end of March 2022 and so does not include the impact of the most recent pay round which includes:

• for consultants the government accepted the recommendation of the DDRB and increased basic pay scales by 4.5%. Rates for clinical impact awards were unchanged.
• for SAS doctors this marked the second year of the multi-year agreement. New starters and those who transferred to the new contracts received awards in line with the framework agreement. Salary scales for the staff grade, specialty, and associate specialist group of practitioners on pre-2021 contracts increased by 4.5% to basic pay.
• this is the final year of the 2018 junior doctor pay agreement. Basic pay for those in the first 4 nodal points (F1 - ST5) increased by 2% while nodal point 5 (ST6-8) increased by 7%. This figure is calculated using the 2022-2023 rate of £58,398 with the average of the rate applied in 2021 to 2022 of £54,577 (April to September = £53,077, October to March = £56,077)
• the pay scales for salaried primary care dental staff have been increased by 4.5%.
• the minimum and maximum of the pay range for salaried GPs employed on the salaried GP contract have been increased by 4.5%

Additional earnings

Additional earnings are the difference between basic pay and total earnings and can be earned by staff working additional hours, working at unsocial hours or, for consultants, being in receipt of either local clinical excellence awards or national clinical impact awards.

Figure 5.1 shows the contribution of additional earnings to total pay in the 12-months to March 2022 and is split by medical career grade. Overall, just under a quarter of total pay is from sources other than basic pay which is broadly similar to last year and there have been only small changes in this proportion across most staff groups apart from some junior doctor grades where the proportion has continued to fall as the number of staff on the old junior doctor contract reduces.

Figure 5.1: additional earnings (non-basic pay) as proportion of total earnings by medical career grade - 12 months to March 2022

Source: NHS Digital earnings statistics

The DDRB has previously asked about the use of recruitment and retention premia (RRPs) for medical staff. As in previous years only a very small proportion of medical staff receive RRPs with the latest data showing only 0.3% of the workforce received one which is the same as the previous 2 years. More detailed figures for RRPs, including career grade breakdowns, are published by NHS Digital.

Earnings distribution

There will be a range of earnings for individual members of the workforce dependent on their grade, contract and working pattern.

As shown in Figure 5.2 there is evidence of a ‘bi-modal’ distribution in earnings for HCHS doctors with the first peak covering junior doctors and the second peak covering consultants who have higher earnings commensurate with their skills and experience. We also see a long ‘tail’ in the earnings distribution with a small number of doctors with very high earnings which will include those with the highest national clinical impact awards, those who do the most additional activity or are in receipt of other allowances.

Figure 5.2: earnings distribution for HCHS doctors in NHS trusts and core organisations for 12-months to March 2022

Source: NHS Digital earnings statistics. Only includes earnings for substantive staff in the HCHS sector and does not include any other earnings not captured on ESR

Note: chart does not include around 0.3% of doctors with earnings of more than £250,000.

Gross earnings and take-home pay

The figures presented above relate to gross earnings and do not consider changes in tax, national insurance, and pension contribution deductions that affect take-home pay. There have been several changes during 2022 to 2023 that affected take-home pay, including:

• a 1.25% increase in National Insurance rates applying between April and October, which increased deductions from gross earnings over that period
• an increase in the National Insurance primary threshold from July, which decreased deductions from gross earnings
• changes to NHS pension contribution rates in October, which increased or decreased deductions from gross earnings for pension members depending on their earnings and whether they work full-time or part-time. Further changes in contribution rates are planned for 2023

Only the NHS pension contribution changes are specific to NHS staff, with changes in tax and National Insurance deductions affecting employees across the whole economy. Further information on the NHS pension scheme is in chapter 7 on total reward.

Pay growth drivers

Several factors drive changes in average earnings. Some relate to changes in the composition of the workforce, some relate more specifically to pay rates. Table 5.2 presents trends in average earnings growth for HCHS medical staff and its component drivers over recent years.

Analysis is based on the DHSC headline paybill metrics. The paybill metrics use data on workforce earnings and size published by NHS Digital to calculate the paybill cost of employing different types of staff, including pension and National Insurance contributions, and how this has changed over time. Observed growth in pay can then be compared with the pay award to determine if growth is higher or lower than can be explained by the pay award and then to investigate the reasons behind this. The paybill metrics are based on data for NHS Trusts and Core organisations and NHS Support organisations & Central bodies combined, so figures for average basic pay and earnings growth may differ slightly from the figures based on NHS trusts and core organisations in Table 5.1. Growth in earnings per FTE may also differ from growth in earnings per person due to changes in average FTE per person.

Table 5.2: breakdown of average earnings growth for HCHS medical staff

Pay Growth Element	2016 to 2017	2017 to 2018	2018 to 2019	2019 to 2020	2020 to 2021	2021 to 2022
Basic Pay per FTE Growth	2.0%	2.8%	2.3%	3.3%	2.1%	3.0%
Additional Earnings per FTE Growth	1.2%	-1.5%	-2.4%	-2.9%	3.5%	2.8%
Total Earnings per FTE Growth	1.8%	1.7%	1.1%	1.8%	2.5%	2.9%
Of which	-	-	-	-	-	-
(a) Headline Pay Awards	1.0%	1.0%	1.0%	3.4%	2.7%	2.7%
(b) Total Earnings Drift	0.8%	0.7%	0.0%	-1.6%	-0.3%	0.2%
Of which	-	-	-	-	-	-
(b1) Basic Pay Drift (excluding Grade Mix Effect)	0.3%	1.6%	1.2%	0.3%	0.4%	0.2%
(b2) Additional Earnings Drift Impact (excluding Grade Mix Effect)	-0.2%	-1.1%	-1.3%	-1.7%	0.1%	0.0%
(b3) Grade Mix Effect	0.6%	0.2%	0.2%	-0.2%	-0.8%	-0.1%

Source: DHSC headline paybill metrics

Grade mix is based on the HCHS medical staff groups that are presented in NHS Digital published data (and used in Table 5.1).

The impact of headline pay awards on average earnings for doctors in 2021 to 2022 compared to 2020-21 was 2.7%, which reflects the combined effect of:

• 2.8% impact for consultants (average of 3% increase to basic pay scales and no change in the value of clinical excellence awards (CEAs), discretionary points and distinction awards)
• 2.5% impact for junior doctors (average impact across all junior doctors, including those not on the 2016 contract, reflecting 2% increase to basic pay scales with a higher increase for nodal point 5 on the 2016 contract)
• 3% impact for SAS doctors (this is the increase in pay scales for pre-2021 contracts, which applied to most SAS doctors in 2021 to 2022; this is also the average investment into the 2021 contract, though the exact impact on average earnings depends on the pattern of uptake of the new contract - the deviation from 3% impact is included within the earnings drift figure)

Average total earnings grew by more in 2021 to 2022 than the pay awards impact (2.9% vs 2.7%), implying positive earnings drift. Earnings drift reflects the combined effect of:

• a positive ‘basic pay drift’ (excluding grade mix effects) of 0.2% in 2021 to 2022 reflecting wider workforce mix effects such as a shift in the distribution of staff within grades towards higher pay points
• a neutral ‘additional earnings drift impact’ of 0.0%, which indicates neither an increase nor decrease in the overall use of additional earnings payments in 2021 to 2022. The trend over recent years has been affected by the phased implementation of the junior doctor contract reforms introduced in 2016 and the 2018 junior doctor contract refresh, with reduction in the use of banding supplements contributing to negative additional earnings drift impact between 2017 to 2018 and 2019 to 2020. Reduction in the use of banding supplements continued to have some impact in 2021 to 2022 (as junior doctors remaining on the pre-2016 contract move out of the junior doctor workforce), though this was offset in 2021 to 2022 by increases in the use of some other elements of additional earnings, the main contributor being an increase in additional activity payments per FTE for consultants
• a negative ‘grade mix effect’ of -0.1%, reflecting a shift in the workforce towards lower earning medical grades that is junior doctors. consultant, SAS doctor and junior doctor FTEs have all grown over recent years, but since 2019 to 2020 the annual growth in junior doctor FTEs has increased to be higher than consultants, which reflects recent expansion of doctor training posts, increased training post fill rates, and significant international recruitment to junior grades. The grade mix effect in 2021 to 2022 returned to a similar level to 2019 to 2020, following the larger negative effect seen in 2020 to 2021 which was linked to earlier than usual recruitment of foundation year doctors as part of the response to the COVID-19 pandemic

Career pathways, progression and longitudinal analysis

Career advancement

Medical staff benefit from clearly defined routes of career advancement which take them from entering the system after graduation from university through the junior doctor grades and eventually to long term careers as consultants, SAS doctors or GPs.

After graduating from medical school, most junior doctors will enter a training pathway that includes the 2-year foundation programme followed by specialty or core training. The pay system for junior doctor includes a series of 5 ‘nodal points’ with different pay for the different stages of training with higher pay for more advanced trainees. Since 2020 the most senior junior doctors have benefited from a new ‘nodal point 5’ reflecting their skills and service contribution.

There are several career paths open to medical staff depending on their specialty and preferences.

The most common path for those wanting to remain in the hospital sector is the consultant path for those who complete specialty training. The consultant pay structure, established by the 2003 contract is a series of pay steps which doctors progress through over time until they reach the ‘top of scale’ after 19 years in post. Under the 2003 contract progression is automatic based on time served and does not depend on FTE.

Other doctors who wish to remain in the hospital sector may choose the SAS pathway which doctors may either use for a short time while awaiting a consultant opportunity or as a longer-term career route. Once the final pay structure of the 2021 SAS contract is in place as of 1 April 2023, doctors will need to spend a minimum of 3 years on each pay point and evidence achievement against the criteria set out in the pay progression schedule before moving to the next pay point. Due to the nature of the transition, this may vary during the transition period from April 2021 to March 2023. More information on the new SAS contract can be found in chapter 6 (remit groups)

Most individuals who are currently junior doctors can have the reasonable expectation of progressing to a more senior role as a consultant, SAS doctor or GP which offer higher pay compared to junior roles and as such the junior doctor pay scales may be considered as part of a longer career ladder.

Table 5.3 highlights the extent of pay progression in the 4 main national contracts and the total pay progression that is possible between entry into the foundation programme and the top of the consultant pay scale. For example, junior doctors basic pay almost doubles between nodal point 1 (FY1) and nodal point 5 (which takes at least 7 years) and basic pay can nearly quadruple over the full career path from FY1 through to the top of the consultant pay scale.

Table 5.3: minimum and maximum pay values by medical contract in the year 2022 to 2023

Pay journey	Starting basic pay	Maximum basic pay	Increase
Junior doctors	29,384	58,398	98.7%
Specialty doctor (2021 contract)	50,373	78,759	56.4%
Specialist contract (2021 contract)	80,693	91,584	13.5%
Consultants	88,364	119,133	34.8%
Pay route	Starting basic pay	Maximum basic pay	Increase
F1 - Consultant max	29,384	119,133	305.4%

Source - NHS Employers pay circulars - pay values from 1 April 2022

Figure 5.3 shows the current system of pay scales across the 4 main national contracts. Once someone has reached the top of their current pay scale, they would need to move to a different career grade to be eligible for further progression.

Figure 5.3: HCHS medical pay scales by contract and minimum time in post - pay scales as of 1st April 2022

Source - NHS Employers pay circulars. Nodal point 5 for junior doctors is denoted by a dashed line as the length of time at this point differs by specialty and training pathway.

Typical career pathways in HCHS sector

The DDRB have previously asked for information about ‘typical career paths’ for medical staff.

After graduation from medical school all doctors must complete the 2-year ‘foundation programme’ after which most doctors will enter specialty / core training on either a hospital or primary care pathway. Those following a hospital pathway are likely to become consultants or SAS doctors while those on the primary care pathway are hoping to become GPs.

Individuals who obtain their ‘primary medical qualification’ (PMQ) outside the UK, as well as those returning to practice or from other sources may enter at different levels depending on their qualification and experience.

Data from the ESR can be used to show how individuals move between career grades over time and can be used to illustrate the concept of career advancement. Table 5.4 shows movement between career grades for staff employed in the HCHS sector in both 2012 and 2022.

Individuals who were junior doctors in 2012 are highly likely to have progressed to more senior grades with over one-third of those who were junior doctors in 2012 progressing to the consultant grade. While around half were not in the HCHS sector this will include those on the general practice pathway. The remainder of those who were junior doctors in 2012 are either still in training or have entered the SAS workforce.

Around two-thirds of individuals who were consultants 10 years ago were still working in the HCHS sector in 2022. This analysis only covers staff who were employed in both 2012 and 2022. Other staff will have joined in the intervening period at all grades.

Table 5.4: medical career pathways - comparison of medical career grades in 2022 for those employed in HCHS sector in 2012

		consultant (grade in 2022)	SAS (grade in 2022)	junior doctor (grade in 2022)	other grades (grade in 2022)	Not in HCHS (grade in 2022)
	consultant (grade in 2012)	64%	0%	0%	0%	36%
	SAS (grade in 2012)	15%	37%	1%	0%	47%
	junior doctor (grade in 2012)	36%	3%	12%	0%	48%
	other grades (grade in 2012)	3%	3%	1%	22%	72%

Longitudinal pay for hospital doctors

Data from the electronic staff record (ESR), the HR and payroll system used by all Trusts and Foundation Trusts, can be used to analyse pay and earnings for individual members of staff over time. This permits analysis of how employees experience the pay system and goes beyond looking at headline averages which can be impacted by things like grade mix and workforce growth.

Table 5.5 presents data on the change in average basic pay per FTE for around 57,000 medical staff who were employed in the HCHS sector in both 2012 and 2022. The median increase in basic pay per FTE was just over 36% (3.1% per annum (pa) while 25% of the workforce experienced an annual increase of over 8.3% pa which will generally be associated with promotion to more senior grades.

Table 5.5: change in basic pay per FTE for HCHS staff employed in both March 2012 and March 2022

Career grade	Number of doctors	Lower quartile	Median	Upper quartile
HCHS doctors	57,000	27.6%	36.1%	123.2%
Consultant	44,000	27.6%	32.0%	131.2%
Associate specialist	2,000	26.7%	31.6%	40.6%
Specialty doctor	4,000	34.0%	52.5%	84.6%
Staff grade	< 100	15.2%	15.2%	15.2%
Specialty registrar	6,000	58.7%	79.9%	114.0%
Core training	1,000	40.5%	68.4%	97.0%
Other and local doctor grades	1,000	14.1%	22.7%	53.5%

Source: DHSC analysis of electronic staff record. Staff grades shown are the individual’s grade in 2022.

General practitioners earnings and expenses

Data on GP earnings and expenses is published by NHS Digital and is based on a sample from HM Revenue and Customs’ (HMRC) tax self-assessment database. This data is collected in a different format for GPs as they are independent contractors. As the data is based on samples with weighting applied, rather than the whole population, it is subject to sampling error and uncertainty.

As we have highlighted in previous years, the dataset includes contractor and salaried GPs working under general medical services (GMS) and personal medical services (PMS) contracts but does not include GPs who work solely as locums. It is possible that some salaried GPs may not need to complete a self-assessment tax return and as such, these individuals do not appear in HMRC’s tax self-assessment database and therefore cannot be included in the sample. The available data provides information on GPs’ total earnings by headcount, and it is therefore not possible to calculate the split between private and NHS work or to distinguish between full- and part-time workers. Due to concerns about the validity and quality of the analysis, NHS Digital no longer publish experimental data on GP earnings estimates by FTE or working hours bands.

Table 5.6 sets out the average percentage increase in annual earnings for salaried and contractor GPs over recent years, against the uplifts recommended by the DDRB and agreed by government in the corresponding year. There does not appear to be a clear link between agreed government uplifts to pay and changes in average earnings for GPs. As independent contractors, it is for GP partners to determine uplifts in pay for themselves and their employees.

Contractor GPs were stood down from the remit of the DDRB for the duration of the 5-year contract, from the year 2019 to 2020 to the year 2023 to 2024. Salaried GPs were stood down for one year in 2019 to 2020, with a 2% uplift agreed for salaried GPs through contract negotiation.

Table 5.6: average percentage increase in annual earnings for salaried and partner GPs and the recommended and agreed uplifts for the same year (%)

Year	DDRB recommendation	Government response	Average % earnings increase for salaried GPs	Average % earnings increase for GP partners
2015 to 2016	1.0	1.0	-1.4	1.1
2016 to 2017	1.0	1.0	1.3	4.5
2017 to 2018	1.0	1.0	3.2	3.5
2018 to 2019	4.0	2.0	3.8	3.4
2019 to 2020	N/A	2.0 (agreed as part of the 2019 to 2020 contract for salaried GPs)	5.0	3.8
2020 to 2021	2.8 (salaried GPs only)	2.8 (salaried GPs only)	2.0	16.6
2021 to 2022	3.0 (salaried GPs only)	3.0 (salaried GPs only)	Data not published	Data not published
2022 to 2023	4.5 (salaried GPs only)	4.5 (salaried GPs only)	Data not published	Data not published

Source: NHS Digital, GP Earnings and Expenses Estimates, 2020 to 2021, September 2022, tables 1a and 7a

Contractor GPs’ earnings

It is evident that the 2020 to 2021 GP earnings and expenses data shows a significant increase in GP contractor income compared to salaried GPs. This may be partially due to a number of arrangements that were put in place in 2020 to 2021 to help general practice to respond to COVID-19. In particular, general practice played a significant role in the COVID-19 vaccination programme: it is estimated that circa 56% in the initial phases of the vaccination programme were delivered through general practice. Further information on the impact of COVID-19 on contractor earnings is available in the NHS Digital GP earnings and Expenses Estimates, 2020/21.

GP contractors are responsible for meeting the requirements set out in the contract for their practice and they take an income after practice expenses. There is therefore a trade-off between contractor GP earnings, and uplifts to salaried GP pay and other pressures on practice finances. In England, the average pre-tax income for a contractor GP working in either a GMS or PMS (GPMS) contract was £142,000 in 2020 to 2021, a statistically significant increase of 16.6% compared to 2019 to 2020 (compared to an increase of 3.8% in 2019 to 2020). The data presented above represents headcount figures only, so it is not possible to isolate how changes in working hours have impacted earnings.

The data in Table 5.7 shows the change in contractor GP income in England since 2011 to 2012 in both nominal and real terms (2020 to 2021 prices). The latest available UK Income distribution figures published by HMRC, are based on total income subject to tax for the year 2019 to 2020 and do not account for hours worked. Contractor GPs were in the 98th percentile group (£102,000 to £125,000) in that year.

The participation rate (the average proportion of one FTE that is worked by one headcount doctor) for contractor GPs (based on contracted hours of work) in September 2020 was 86.6% (a slight decrease from September 2019 at 87.5%), although this may not accurately reflect actual working hours, particularly ad-hoc additional hours. September 2020 was also prior to the COVID-19 vaccination programme roll out.

Table 5.7 represents average earnings for GP contractors in both GMS and PMS practices. The GMS contract is the national standard GP contract and in 2020 to 2021 around 70% of GP practices operated under it. Expenses are split into categories including office and general business, premises, employee, car and travel, interest, net capital allowance and other (for example, cost of drugs for dispensing GPs).

Table 5.7: earnings and expenses for GP partners in England, GMS and PMS, all practice types, between the year 2011 to 2012 and the year 2020 to 2021

Year	Report population	Estimated gross earnings, cash terms (£)	Total expenses, cash terms (£)	Income before tax, cash terms (£)	Estimated gross earnings, real terms (£)	Total expenses, real terms (£)	Income before tax, real terms (£)
2011 to 2012	26,350	284,300	178,200	106,100	345,900	216,900	129,100
2012 to 2013	26,200	289,300	184,200	105,100	345,000	219,700	125,300
2013 to 2014	25,700	290,900	189,000	101,900	339,100	220,300	118,800
2014 to 2015	25,500	302,600	198,800	103,800	348,800	229,200	119,600
2015 to 2016	18,300	315,600	210,800	104,900	361,600	241,400	120,100
2016 to 2017	19,850	338,300	228,700	109,600	379,100	256,300	122,900
2017 to 2018	20,350	357,300	243,900	113,400	393,500	268,600	124,900
2018 to 2019	20,300	380,900	263,600	117,300	411,600	284,800	126,700
2019 to 2020	19,250	402,600	280,800	121,800	425,300	296,700	128,700
2020 to 2021	18,600	438,700	296,700	142,000	438,700	296,700	142,000

Source: NHS Digital, GP earnings and expenses estimates, 2020 to 2021, September 2022, tables 1a and 1b. The conversion to real terms has been carried out using gross domestic product (GDP) deflators as at June 2022 available from HMT.

The dataset shows total earnings, expenses and income (pre-tax). ‘Earnings’ is the total that GPs receive; however, expenses come out of this sum, meaning that ‘income’ is total earnings minus expenses. Mean values are presented for earnings and expenses. Estimates have been rounded to the nearest £100, so numbers presented for taxable income may not equal gross earnings minus total expenses and the sum of numbers in a table may not equal the total.

Salaried GPs’ earnings

GPs can work in a range of settings, however the data below is specific to those working in general practices. Salaried GPs should be on a salary no less favourable than the minimum pay range in the model terms and conditions, as set out by NHS Employers and the model salaried GP contract. In responding to the DDRB’s recommendations, government will adjust the minimum and maximum pay threshold accordingly. It is, however, up to practices to determine the pay uplift for their staff.

For the year 2020 to 2021, GP earnings and expenses data shows a significant increase in GP contractor income compared to salaried GPs and a decrease in salaried GP pay uplift compared to the 2019 to 2020 year. Further information on the impact of the COVID-19 pandemic on GP earnings is in the NHS Digital GP earnings and expenses estimates, 2020 to 2021.

Table 5.8 below shows the change in salaried GP income in England since 2011 to 2012 in both nominal and real terms (2020 to 2021 prices). The average pre-tax income of salaried GP working in either a GMS or PMS (GPMS) contract was £64,900, a statistically significant increase of 2% in cash terms compared to 2019 to 2020 (compared to an increase of 5% in 2019 to 2020).

The UK income distribution figures from 2019 to 2020, show that salaried GPs were in the 92nd percentile group (£61,2000 to £64,700) for that year. The participation rate for salaried GPs in September 2020 was 64.8% (a decrease since September 2016 at 66.9%), although this may not accurately reflect actual working hours.

Table 5.8: earnings and expenses for salaried GPs in England, GMS and PMS, all practice types, between 2011 to 2012 and 2020 to 2021

Year	Report population	Gross employment earnings, cash terms (£)	Gross self-employment earnings, cash terms (£)	Total gross earnings, cash terms (£)	Total expenses, cash terms (£)	Total income before tax, cash terms (£)	Total gross earnings, real terms (£)	Total income before tax, real terms (£)
2011 to 2012	7,050	49,600	14,800	64,400	7,300	57,000	78,300	69,400
2012 to 2013	7,550	49,200	15,500	64,700	8,100	56,600	77,200	67,500
2013 to 2014	8,000	48,200	15,800	64,100	9,200	54,900	74,700	64,000
2014 to 2015	8,750	50,800	14,700	65,500	8,700	56,700	75,500	65,400
2015 to 2016	7,250	51,500	12,300	63,900	7,900	55,900	73,200	64,100
2016 to 2017	8,550	51,700	13,700	65,300	8,700	56,600	73,200	63,400
2017 to 2018	9,400	52,400	15,800	68,200	9,800	58,400	75,200	64,400
2018 to 2019	10,500	53,700	16,400	70,100	9,400	60,600	75,700	65,500
2019 to 2020	11,000	55,300	16,300	71,600	8,000	63,600	75,700	67,200
2020 to 2021	11,950	57,200	15,300	72,200	7,400	64,900	72,200	64,900

Source: NHS Digital, GP earnings and expenses estimates, 2020 to 2021, September 2022, tables 7a and 7b. The conversion to real terms has been carried out using gross domestic product (GDP) deflators as of June 2022 available from HMT.

GP trainer grants

Working with Health Education England, the department continues to work with stakeholders to promote a fair and equitable approach to the funding of clinical placements in GP practices, irrespective of geography and historical arrangements.

From 1st September 2022 the 2022 to 2023, the annual Education and Training tariff guidance introduced a harmonised national tariff price of £30,750 plus Market Forces Factor for all Undergraduate Medical placement activity, irrespective of setting, across primary care and secondary care.

NHSE submission will contain information on GP appraiser rates.

Dental practitioner earnings and expenses

Data on earnings and expenses is available for self-employed primary care dentists who have completed some NHS work during the financial year, however figures relate to both NHS and private income. Private earnings are determined by the amount of demand from individual patients, which may be in addition to NHS care. In 2020 to 2021 the average taxable income for all dentists in increased slightly from 2019 to 2020 to £72,500. The expenses to earnings ratio decreased by 3.9%, to 48.7%. See Table 5.9.

A 4.5% pay uplift was awarded to dentists in 2022 to 2023, to be backdated to 1 April 2022. Whilst each year we recommend that provider-performer dentists apply this to their associate dentists’ salaries, as practices are private businesses it falls to them to set employee pay and conditions.

We understand that the DDRB requested the rationale and the method around expenses uplifts. While pay uplifts for General Dental Services and Personal Dental Services contracts are uplifted in line with the DDRB process (4.5% for 2022 to 2023), expenses (costs) are uplifted in line with inflation at the same time each year. The final uplift figure applied to the value of each contract combines both the DDRB uplift rate (for pay) and the inflation uplift rate (for expenses) based on proportion of pay (68%) and expenses in the contract (32%). Each year, we consult with the BDA on the uplift proposals, for both pay and expenses.

We understand that the DDRB requested information on the bidding process in place in England and Wales, how this may affect remuneration, and identification of any checks and balances in place to ensure that bidders for dental contracts do not undermine their viability by bidding below a sustainable level. NHS England manage the commissioning of NHS dental contracts, including bidding processes, and therefore would be best placed to answer this.

Table 5.9: gross income, expenses and taxable income for all dentists between 2009 to 2010 and 2020 to 2021

	Average Gross Earnings	Average Expenses	Average Taxable Income	Expenses ratio
2009 to 2010	£184,900	£100,000	£84,900	54.1%
2010 to 2011	£172,000	£94,100	£77,900	54.7%
2011 to 2012	£161,000	£86,600	£74,400	53.8%
2012 to 2013	£156,100	£83,500	£72,600	53.5%
2013 to 2014	£155,100	£83,400	£71,700	53.8%
2014 to 2015	£152,500	£82,000	£70,500	53.8%
2015 to 2016	£148,000	£78,900	£69,200	53.3%
2016 to 2017	£145,700	£77,000	£68,700	52.9%
2017 to 2018*	£146,700	£78,100	£68,500	53.3%
2018 to 2019*	£147,100	£78,500	£68,600	53.4%
2019 to 2020*	£144,700	£76,100	£68,600	52.6%
2020 to 2021*	£141,400	£68,900	£72,500	48.7%

Source: Dental earnings and expenses estimates 2020 to 2021, NHS Digital

In England, the earnings of a dentist are dependent on whether they are a provider-performer dentist or an associate dentist. Provider-performer dentists hold a contract with NHS England to provide a given number of units of dental activity or units of orthodontic activity. Associate dentists work as performers under a contract. They deliver NHS dental services and hold a contract with their provider-performer but do not hold a contract with the NHS. Generally, provider-performers tend to earn more (higher gross earnings and taxable income). In 2020 to 2021 providing-performer dentists had an average taxable income of £128,800, a large increase from £108,000 in 2019 to 2020. Associate dentists also saw their average taxable income increase, by a smaller amount to £57,400 in 2020 to 2021 compared to £56,900 in 2019 to 2020. Tables 5.10 and 5.11 show taxable income, in cash and real terms, for provider-performer dentists and associate dentists in England.

A number of factors make it difficult to compare the level of earnings and gross income from one year to another. These factors include variations in hours worked, in the balance between NHS and private sector activity, the evolving nature of practice business models, the new methodology used to collect data and the rise in practices becoming corporates or parts of corporates.

Table 5.10: taxable income, in cash and real terms, for provider-performer dentists

Year	Average taxable income	GDP (real terms)	CPI (real terms)	RPI (real terms)	RPIX (real terms)
2017/2018	£113,200	£124,600	£118,400	£121,100	£121,300
2018/2019	£113,100	£122,200	£115,800	£117,500	£117,700
2019/2020	£112,600	£119,000	£113,300	£114,000	£114,200
2020/2021	£132,200	£132,200	£132,200	£132,200	£132,200

Table 5.11: taxable income, in cash and real terms for associate dentists in England

Year	Average taxable income	GDP (real terms)	CPI (real terms)	RPI (real terms)	RPIX (real terms)
2017 to 2018	£57,000	£62,800	£59,600	£61,000	£61,100
2018 to 2019	£57,600	£62,200	£59,000	£59,800	£59,900
2019 to 2020	£58,100	£61,400	£58,500	£58,900	£59,000
2020 to 2021	£58,700	£58,700	£58,700	£58,700	£58,700

Source: NHS, Dental earnings and expenses estimates, 2020 to 2021.

Equalities and pay disparities

The government is committed to ensuring that the pay system is fair to all members of staff and that any disparities between groups, which may be explained by past or present patterns of entry grades, promotion or working patterns are removed. This section sets out information on some of these but is not a comprehensive overview. Chapter 4 contains more equality data which may be useful in interpreting these figures.

Gender and ethnicity pay gaps (EPG)

The government is committed to eliminating pay gaps which occur when men are paid more than women (gender pay pap), or white staff are paid more than staff from ethnic minority groups (ethnicity pay gaps).

Mend the Gap: the independent review into gender pay gaps in medicine in England (‘GPG Review’) published in 2020, undertook analysis to establish the size of pay gaps in medicine and to better understand the reasons why they develop. A similar piece of work is in development for ethnicity across the whole NHS workforce.

Factors that can contribute to a pay gap developing include differences in:

• staff group mix - a gap will develop if male or white staff are more likely to be in more senior staff groups compared to female or ethnic minority staff
• career grade mix - a gap will develop if male or white staff are more likely to be in more senior career grades compared to female or ethnic minority staff
• point mix - a gap will develop if male / white staff are more likely to be further up established pay scales than female or ethnic minority staff

When considering pay gaps across the entire medical (or HCHS) workforce the impact of career grade group mix is strongest while pay gaps within individual staff groups reflect differences in grade and point mix.

Gender and ethnicity pay gaps in HCHS sector

Table 5.12 presents the latest data on the gender and ethnicity pay gap as of May 2022 and are based on basic pay per FTE. Gender and ethnicity are shown separately to isolate the impact of either factor

Table 5.12: gender and ethnicity pay gap for HCHS doctors using basic pay per FTE definition - May 2022

Staff group	GPG - white	GPG - ethnic minority	EPG - female	EPG - male
Description	Comparison of white female & white male	Comparison of ethnic minority female & ethnic minority male	Comparison of ethnic minority female & white female	Comparison of ethnic minority male & white male
HCHS Doctors	-11%	-13%	-13%	-11%
Consultants	-3%	-2%	-2%	-3%
SAS Doctors	0%	-5%	-5%	0%
Doctors in Training	-1%	-4%	-3%	0%

Source: NHS Digital earnings statistics

Table 5.12 is based on differences in basic pay per FTE. A similar table based on differences in average earnings per person would also be impacted by any variation in working patterns or additional earnings between different groups of staff.

Overall, male and white doctors are paid more than female and ethnic minority doctors’ average earnings for white female are around 11% lower than for white males and BME females around 13% lower than for white females. These results are very similar when compared to last year.

Gender pay gaps in GP sector

Mean earnings, expenses and income by age group and gender for salaried and contractor GPs in England are set out in Table 5.13 and 5.14. As with previous years, the data shows that for both contractor and salaried GPs, men earn more on average than female GPs in each age category, with the difference in average pay reducing in GPs over 60 years old.

GP earnings data does not take account of part time working and average participation rates are lower for female GPs than male, so it is not possible to assess the extent to which differences in working patterns may explain the observed earnings differences between male and female GPs of different ages.

As the department mentioned in evidence from previous years, the GPG (gender pay gap) Review found that the mean gender pay gap for net income before tax in the 2016 to 2017 tax year was 22.6% among contractor GPs and 31.1% among salaried GPs. The report found the FTE-corrected mean gender pay gap was substantially lower for contractor GPs at 7.7% but remained high for salaried GPs at 22.3%. However, there are known limitations with the analysis, which used total income figures based on HMRC’s self-assessment tax records and contracted hours or average weekly hours taken from NHS Digital’s workforce minimum data set (wMDS). This collection does not capture the actual number of hours worked and any hours worked outside of a general practice setting would not be accounted for.

Table 5.13: average GP partner earnings and expenses in England by age and gender, GMS and PMS, all practice types, 2020 to 2021

Age	Gender	Report population	Average total gross earnings (£)	Average total expenses (£)	Average total income before tax (£)	Comparison of female to male (%)
Under 40	Female	1,400	362,500	246,000	116,500	-23%
Under 40	Male	1,400	447,400	296,300	151,000	-23%
40 to 49	Female	3,550	398,800	271,300	127,500	-20%
40 to 49	Male	3,600	491,800	332,500	159,300	-20%
50 to 59	Female	2,950	403,200	277,100	126,100	-21%
50 to 59	Male	3,600	497,000	337,000	160,000	-21%
Over 60	Female	550	384,400	256,800	127,700	-11%
Over 60	Male	1,500	418,800	275,200	143,500	-11%

Source: NHS Digital, GP earnings and expenses estimates, 2020 to 2021, September 2022, table 2a. Earnings and expenses estimates are only available for GPs in England and were calculated for the first time for 2016 to 2017. The percentage difference is calculated as the mean (average) difference in average total income before tax as a percentage of men’s pay.

Table 5.14: average salaried GP earnings and expenses in England by age and gender, GMS and PMS, all practice types, 2020 to 2021

Age	Gender	Report population	Average total gross earnings (£)	Average total expenses (£)	Average total income before tax (£)	Comparison of female to male (%)
Under 40	Female	4,600	62,300	4,900	57,400	-29%
Under 40	Male	1,500	94,200	13,500	80,700	-29%
40 to 49	Female	2,800	67,300	6,700	60,600	-27%
40 to 49	Male	750	91,200	8,400	82,900	-27%
50 to 59	Female	1,200	70,600	6,500	64,200	-26%
50 to 59	Male	500	100,700	13,400	87,300	-26%
Over 60	Female	250	58,300	5,900	52,400	-24%
Over 60	Male	300	80,400	11,600	68,700	-24%

Source: NHS Digital, GP earnings and expenses estimates, 2020 to 2021, September 2022, table 8. Earnings and expenses estimates are only available for GPs in England and were calculated for the first time for 2016 to 2017. The percentage difference is calculated as the mean (average) difference in average total income before tax as a percentage of men’s pay.

The Gender Pay Gap Implementation Panel

The panel is independently chaired by Professor Dame Jane Dacre. Membership is wide ranging and includes senior leaders from across the health system, representing among others, NHSE, NHS Employers and the Trade Unions. The panel have agreed the second-year work programme, informed by the recommendations from the GPG review and the progress from the first year. The work plan is soon to be submitted to the Minister of State for Health. Policy teams across the department are working closely with colleagues in partner organisations to deliver the programme. Quarterly progress updates are submitted to the panel for review. 

The work of the panel underpins our ambition to embed pay gap considerations into policy development and we are already seeing successful outcomes for example, through the reduction in pay points agreed in the SAS contract reform. 

The panel is making positive progress on multiple recommendations across all 7 themes identified in the review and will continue to work on recommendations throughout 2023.

The ethnicity pay gap review

NHSE are conducting a research project examining the EPG across the NHS. The research aims to analyse pay related data in a manner that gives a clearer and more accurate picture of where there are potential ethnic inequalities in pay and, presenting recommendations aimed at reducing inequalities where they exist.

Wider economy comparison

This section will provide an assessment of how earnings for the medical workforce compare with both the wider economy in general and other professions towards the top of the earnings distribution.

As set out in HMT’s economic evidence to PRBs, public sector earnings growth should retain broad parity with the private sector and continue to be affordable.

According to surveys by XpertHR, median private sector pay settlements, analogous to the pay awards recommended by the pay review bodies, were 3.5% in the last quarter on 2021 to 2022 and 4% in the first quarter of 2022 to 2023, broadly in line with the 2022 to 2023 pay awards for medical staff covered by the DDRB remit of 4.5%

Available evidence from the Annual Survey of Hours and Earnings (ASHE) point to Medical Practitioners being one of the total earnings occupation groups and average returns to those with a degree in medicine or dentistry are high.

Evidence also suggests that medical grades have retained their position within the overall income distribution.

When considering wage growth and pay settlements in the wider economy and comparator sectors, it is important to consider a range of sources as there is no single definitive data source. Instead, we should look across available indicators for the best view of the current, and prospective position. We are basing our expectations of comparable pay growth across the economy in 2023 to 2024 on OBR average earnings growth forecasts. They suggest it will fall to 3.5% as the labour market loosens. Please see HMT’s economic evidence for more commentary on the relationship between average earnings growth and settlement.

Comparison with the wider economy - average weekly earnings

ONS publish data on average weekly earnings which is the lead measure on average weekly earnings per employee and is based on data collected from the monthly wages and salaries survey. These estimates cover more than just pay settlements and will include the impact of factors including changes in average working hours or changes in the composition of the workforce which was of particular importance during the COVID-19 period when the furlough scheme was reducing the pay of over a million employees.

Figures, for the period to September 2022, show that across the whole economy average total pay increased by 6% compared with the same period 12 months ago and average regular pay (excluding bonuses) increased by 5.7%. In both cases these figures are below the level of inflation which mean that real total pay has fallen by 2.6% and real regular pay (excluding bonuses) has fallen by 2.7%. This indicates that pay settlements in the wider economy are not keeping pace with the current very high levels of inflation.

Figure 5.4: increase in average weekly earnings, 3-month and annual growth rates

Source: Office for National Statistics, average weekly earnings (all sectors)

Separate data, based on HMRC pay as you earn (PAYE) data, shows that earnings have increased across the earnings distribution. In the 3 months to August 2022 earnings increased by between 5% and 7% at all points of the earning distribution above the lower quartile. Earnings growth was lowest at the 10th percentile although the earnings level (£700pm) indicates people not working full-time hours.

Table 5.15: comparison of average monthly pay at different points in the United Kingdom wage distribution from HMRC real-time information

	Percentile
	10th	25th (LQ)	50th (Median)	75th (UQ)	90th	95th	99th
£ Per Month	697	1,220	2,128	3,331	5,063	6,897	14,384
Annual Increase	3.4%	5.9%	6.7%	6.4%	6.8%	6.4%	5.9%

Source: Office for National Statistics, HMRC real-time information - seasonally adjusted

Latest forecasts for whole economy pay growth, published by The Office for Budget Responsibility (OBR), are for average earnings to increase by 5.4% in 2022 to 2023, 3.5% in 2023 to 2024 and 1.6% in 2024 to 2025 which will include the impact of pay settlements, changes to workforce composition and pay drift. More information is available in HMT evidence.

The Annual Survey of Hours and Earnings (ASHE)

The annual survey of hours and earnings (ASHE) provides information about the levels, distribution, and make-up of earnings for employees across the UK and is based on a sample of around 1% of the pay as you earn (PAYE) register covering around 180,000 jobs from 60,000 employers. ASHE includes information of medical practitioners and from 2021 can be split into ‘specialist’ and ‘generalist’ groups.

Using ASHE, it is possible to make consistent comparisons between occupations but is not directly comparable to the NHS data in earlier parts of this chapter:

• as ASHE data is based on a sample of around 1% of PAYE records while NHS data may be sourced from administrative data sets covering the whole workforce
• as ASHE is based on PAYE data it does not cover people who use the self-assessment system (for example, partner GPs)
• the ASHE data presented here is based on ‘gross median earnings per person’ - other tables in this chapter may have used other definitions (for example, mean earnings per person)

There are also additional factors which are important to consider when analysing 2022 data:

• the Office for National Statistics note that data for 2020 and 2021 was impacted by the COVID-19 pandemic with changes to the composition of the workforce and changes to earnings due to the Coronavirus Job Retention Scheme (furlough) impacting earnings levels and lower response rates potentially impacting the accuracy of data. As such it may be better to look at trends over longer time periods.
• from 2021 the system of ‘standard occupation codes’ has been updated. As a result, there is a break in the series prior to 2021 and results are not directly comparable as some occupations will have moved classification groups and in the case of medical Practitioners staff have been divided into ‘specialist’ and ‘generalist’ groups.
• ASHE data is measured in April of each year and therefore the 2022 data won’t reflect 2022/23 awards in the public sector which didn’t reach pay packets until later in the year. However, it will capture some 2022 pay awards in the private sector, which are concentrated in January and April

Earnings percentiles analysis

One way to assess any change in the competitiveness of medical pay is to consider how the average earnings of different grades compare with the UK income distribution.

As shown in Table 5.16, there have been only very small changes in the relative ranking of the different medical grades over time - HCHS doctors are consistently in the top 5% of the UK earnings distribution with consultants in the top 2% of earners. Average earnings for junior doctors are also above the UK average pay with only foundation doctor year 1 not in the upper quartile of the earnings distribution.

This suggests that HCHS doctors have retained their position in the overall income distribution since 2017 with only very small changes in percentiles over the period. Changes over the COVID-19 period should be treated with caution due to the impact that COVID-19 had on employee earnings (for example, furlough) and data collection and so it is advised to look for longer term trends.

Table 5.16: estimated income percentile for NHS career grades based on average earnings per person in NHS mapped against annual survey of hours and earnings

Medical grade	2017	2018	2019	2020	2021 (SOC10)	2021 (SOC20)	2022
All HCHS doctors	96	96	96	96	96	96	96
Consultant	98	98	98	98	98	98	98
Associate specialist	97	97	97	97	97	97	97
Specialty doctor	94	93	93	93	94	94	94
Staff grade	93	93	92	92	93	94	94
Specialty registrar	92	91	91	91	91	92	92
Core training	86	86	87	87	86	89	89
F2	79	79	79	79	77	80	80
F1	69	69	70	70	67	69	69

Source: NHS Digital earnings statistics, annual survey of hours and earnings. Based on a comparison of NHS average earnings per person with gross total pay from annual survey of hours and earnings. Note - this may differ slightly from previous OME analysis as this is based on average earnings per person rather than FTE salaries.

Comparison with other high-income professions

As previously demonstrated medical staff can have relatively high earnings compared to the wider population but it can also be useful to look at how earnings for medical practitioners have compared to other ‘high income’ professions as well and more generally against the top of the wage distribution.

As previously mentioned, the most recent ASHE data uses a new coding framework which can be used to separate medical practitioners into ‘specialists’ and ‘generalists’ groups.

Firstly, we might want to consider the position for the combined group which is more similar to previous iterations. Table 5.17 shows ‘3-digit’ grouping with median earnings of at least £45,000. Medical practitioners, which include both specialists and generalists are shown to have median average earnings of just under £55,000.

Over the longer term we show that medical practitioners have consistently been in the top 5 of professions on this basis showing they remain a profession toward the top of the income distribution. As previously noted, the reduction in median earnings since 2012 is not consistent with data from other sources which show increases in earnings over the period.

Table 5.17: ranking of medical practitioners median gross annual earnings compared to the wider population in 2012, 2017 and 2022

Group	SOC10 Code	SOC20 Code	2012 Median gross annual earnings (SOC10)	Rank	2017 Median gross annual earnings (SOC10)	Rank	2022 Median gross annual earnings (SOC20)	Rank
Chief executives and senior officials	111	111	76,732	1	81,302	1	67,026	1
Transport associate professionals	351	351	60,809	3	75,487	2	61,845	2
Functional managers and directors	113	113	51,801	5	56,760	4	57,337	3
Senior officers in protective services	117	116	54,923	4	56,651	5	57,179	4
Medical practitioners	2211	221	61,007	2	61,289	3	54,663	5
Other drivers and transport operatives	823	823	38,314	10	40,947	10	49,136	6
Business and financial project management professionals	2424	244	41,999	7	45,355	6	48,780	7
Health and social services managers and directors	118	117	41,151	8	40,988	9	46,172	8
Information technology professionals	213	213	39,024	9	41,837	8	45,826	9
Research and development and other research professionals	215	216	42,759	6	45,101	7	45,057	10

Source: annual survey of hours and earnings

Taking advantage of the greater granularity in data median average earnings are around £64,000 for specialist medical practitioners and just over £41,000 for general medical practitioners. In the case of specialist medical practitioners this is in the top 10 of all ‘4-digit’ occupations with the median for the general group also being above the national average.

This difference can partly be explained by the composition of the different groups - The specialist group includes consultants and more senior registrars while the general group will include foundation doctors as well as salaried GPs. As ASHE is based on PAYE records it will not include those who do not use the PAYE system including partner GPs who, as shown in table 5.21, have higher incomes than salaried GPs.

Table 5.18: median gross annual earnings for medical practitioners, and its component parts, in 2022

Group	Code	Median Gross Annual Earnings
Medical Practitioners	221	54,663
Specialist Medical Practitioners	2212	64,026
General Medical Practitioners	2211	41,187

Source: annual survey of hours and earnings

Graduate level outcomes

Data from the Longitudinal Education Outcomes (LEO) dataset can be used to monitor employment and earnings outcomes for graduates and postgraduates from English higher education providers one, 3, 5 and 10 years after graduation based on information provided by the Department for Education, the Department for Work and Pensions and HMRC. The data can be used to compare outcomes for healthcare graduates (including nursing graduates) against those from other courses.

Table 5.19 compares median earnings for medicine and dentistry graduates to median earnings for graduates from other subjects 1,3,5 and 10 years after graduation - it shows that median earnings for those that take medicine and dentistry have the highest average earnings throughout the first 10 years after graduation. Earnings after 1 year of graduation are just under 73% higher than the subject average, this figure rises to 75% after 10 years.

Table 5.19: median earnings for medicine and dentistry graduates 1,3,5 and 10 years after graduation with comparison to all other subjects

Average earnings for first degree students	1 year after graduation	3 years after graduation	5 years after graduation	10 years after graduation
Medicine and dentistry	£37,300	£46,800	£50,100	£56,400
Medicine and dentistry rank (34 Subjects)	1	1	1	1
All subjects (Student weighted)	£21,600	£25,100	£28,200	£32,200
Subject average (No weight)	£22,335	£26,718	£29,894	£34,014

Source - Longitudinal Education Outcomes (Department for Education)

LEO also includes information on employment which shows that individuals with Medicine and Dentistry degrees are more likely to be in sustained employment or training at all stages after graduation. Although this falls as the years since graduation increase. This is shown in table 5.20.

Table 5.20: proportion of medicine and dentistry first degree graduates in sustained employment, training or both after 1,3,5 and 10 years with comparison to other subjects

Proportion in sustained employment, training or both (first degree only)	1 year after graduation	3 years after graduation	5 years after graduation	10 years after graduation
Medicine and dentistry	96.7	93.1	92.1	87.5
Medicine and dentistry rank	1	3	2	4
All subjects (student weighted)	88.4	88	86.8	84.3

Source: Longitudinal Education Outcomes (Department for Education)

Comparison with the wider economy

The first comparison to draw is between average earnings for ‘medical practitioners’ with those of the rest of the economy.

Figure 5.5 shows the evolution of median earnings for ‘medical practitioners’ and the wider UK economy using data from the ASHE. On this measure there has been a reduction in the ratio as pay has grown in the overall economy (26% median, 32% mean) while average earnings for medical practitioners have reduced (13% median, 5% mean).

The reduction in earnings since 2012 in this data is not consistent with data from NHS Digital for the HCHS sector which show an increase in average earnings for HCHS doctors of 17% over the past 10 years. Potential explanations for this difference may include changes in the composition of the total medical workforce including an increase in the proportion of junior doctors or be caused by sampling effects. While the estimates for medical practitioners are considered by ASHE to be ‘reasonably precise’, any estimate based on a sample is more uncertain than one based on the entire population as the sample may in advertently over or under represent different grades. Office for National Statistics (ONS) also note that ASHE data may have been impacted throughout COVID-19 due to changes in the composition of the workforce, the impact of furlough and issues with data collection.

Figure 5.5: median annual earnings per person for medical practitioners and UK economy - 2011 to 2022

Source: annual survey of hours and earnings

International comparisons

The DDRB requested additional information on how medical pay in the UK compares to other countries. The Organisation for Economic Co-Operation and Development (OECD) publish some information on how average pay for medical staff in the respective countries compare with the national average pay. For more information see the OECD’s ‘Remuneration of doctors (general practitioners and specialists’. Across the OECD, including the UK, it shows that medical staff consistently earn well above the average in their respective countries. We do however note that it is exceptionally difficult to make appropriate comparisons between countries due to differences in things like workforce definitions, qualifications or differences in the total reward package across jurisdictions. Therefore, we do not believe that international comparisons are very informative to pay setting.

6. Remit groups

Consultants

In 2022 to 2023, the government accepted the DDRB’s recommendations and uplifted pay for consultants by 4.5%. This increased the consultant pay scales by between £3,805 and £5,130. As recommended by the DDRB, the values of local Clinical Excellence Awards (LCEAs) and National Clinical Impact Awards (NCIAs) were not uplifted.

The current starting salary for a consultant is £88,364. In addition to the annual pay uplifts, the 2003 contract for consultants in England provides incremental pay progression at a number of points during a consultant’s career. A consultant with 19 years’ experience will currently earn a salary of £119,133.

This does not include additional earnings consultants have access to, including on-call allowances, LCEAs, NCIAs, Additional Programmed Activities and management allowances. On average consultants earn £122,449 from NHS work, with additional NHS earnings making up about 23% of this total. Consultants are consistently amongst the highest 2% of earners in the UK income distribution.

The NHS staff survey results repeatedly show that consultants are the most satisfied of all staff groups with their pay. Results from the survey conducted in Autumn 2021, showed 59.6% of consultant respondents reporting being happy with their pay. We recognise that rates of satisfaction with pay fell amongst consultants and across all workforces in 2021 and note that this is consistent with a fall in many of the other metrics collected in the survey. Results for the 2022 survey are yet to be published.

Consultant activity

In the 2021 report the DDRB asked for data on the trends in the average number of programmed activities (PAs) and supporting professional activities (SPAs) worked. The department does not hold specific data on the breakdown of PAs and SPAs, but there are several indicators that can be used from published NHS Digital data to understand more about overall working patterns.

By comparing the headcount of consultants to the number of full-time equivalents (published by NHS Digital), we have looked at trends in participation rates to determine whether there is any evidence that consultants are reducing their hours and moving more towards part-time working. This shows that the participation rate has remained relatively stable between around 0.95 and 0.93 from March 2016 to July 2022 but has been on a slight downward trend. Taking into account the increase in females in the consultant workforce (from 35% in September 2016 to 39% in June 2022), who are proportionately more likely to work less than full time, this small reduction in rates of participation may be expected.

Many consultants will take on additional activity on top of their standard contracted hours. Some of this will be regular activity agreed as part of job plans (additional PAs) and some will be of an ad-hoc nature. NHS Digital publish data on the percentage of consultants receiving a payment for additional activity. Again, this has been relatively stable. The proportion of consultants taking on additional activity began to drop prior to COVID-19 in September 2019 from around 61% to around 59% by the end of 2020. This decline which may be expected during the first year of COVID-19, has since reversed steadily to just under 60%.

Another indicator of consultant additional activity is NHS Digital data on additional activity earnings per person. Average additional activity payments per consultant that received some payment for additional activity increased from £21,439 in the year to December 2019 to £23,663 in the year to June 2022. Whilst this reduced during the COVID-19 pandemic, it has recovered and represents a 10.4% increase from December 2019 to June 2022. This suggests that, on average, those who take on additional activity have been doing more additional activity compared to pre COVID-19, though the increase will also reflect elements of pay growth for the period. We estimate that annual pay awards accounts for around three-quarters of this increase, suggesting there has been net growth in additional activity.

The contract for consultants in England allows for local agreement of rates of pay for extra-contractual work, such as catch-up work and extra lists. There is no national collectively agreed rate for this type of work. In September 2022 the BMA produced a ‘rate card’ for extra contractual work, encouraging their members to withdraw from existing applicable work commitments not paid at this rate (a similar rate card was also produced for SAS doctors). We understand that there was no national level discussion with employer representatives prior to issuing the rate card and no attempt to agree mutually acceptable rates. The card values extra contractual work between the hours of 7am and 7pm at minimum rate of £150 for consultants, which is more than 3 times the standard hourly rate of pay for the lowest earning consultants. It remains to be seen whether there will be a resulting impact on either the amount of extra-contractual work undertaken or the cost of such work and whether this will have a direct impact on service recovery following COVID-19.

Growth in consultant workforce

Over recent years the number of consultants has continued to increase steadily. Between June 2018 and June 2022, numbers have increased by 13.9%, with 53,111 consultants in June 2022.

Many stakeholders have expressed a concern that the trend in consultant growth may stall due to the after-effects of COVID-19 and concerns among consultants around the impacts of pensions tax. However, evidence on this issue is mixed. In the year to September 2022 consultant numbers increased by 2.7% over 1400 FTE. Nevertheless, it is important that actions are targeted at retaining highly experienced individuals and ensuring that the total reward package for all consultants in the NHS remains attractive and is supported by positive experiences of working.

Chapter 7 sets out detail of some of the interventions and resources which have been put in place to enhance the total reward package and improve retention.

Contract reform

For a number of years, we have highlighted in our evidence our ambitions to press forward with reform of the consultant contract.

In the current fiscal climate difficult decisions need to be made on spending priorities. Additionally, pressures within the system will require attention to be focused on service recovery. As a result, we have not been in a position to make progress on full scale contract reform, and it remains unlikely that we will be able to initiate a full programme of reform in the near future.

However, we do not think it would be the right thing to completely put on hold our ambitions for reform which would bring about benefits to consultants and to the service. As such we remain keen to examine what smaller scale reform may be possible within these parameters and within our affordability envelope. For example, we would like to consider how we can make more substantial progress on addressing some of the recommendations made by the independent review into gender pay gaps in medicine. We believe that this should be a priority shared by the trade unions and other stakeholders.

One of the priorities we have previously highlighted relates to the length and structure of the pay scale. There may be some opportunity in the future to consider ways in which the annual pay uplifts can be used pending full contractual reform. For example, one option could be making incremental changes to rates of pay for certain pay points to start the move towards merging pay points and reducing the overall time taken to reach the top of the pay scale. The aim would be to contribute to reducing gender pay gaps and to more closely link the top of the pay scale with the time it takes to become fully effective in the role. Our view is that, if done gradually over a number of years, this could be achieved within the affordability envelope for pay by differentially distributing funds and targeting larger and smaller uplifts at certain pay points. Whilst this kind of reform may mean some staff receiving lower uplifts in the short term, there would be benefit to consultant career earnings from reaching the top of the pay scale sooner in a doctor’s career. This way, reform could be realised gradually to ensure that impact of lower uplifts is minimised.

We strongly believe that it should be a collective priority of all parties to make progress on reform. We would be very interested in working with the trade unions to jointly develop proposals on how improvements can be made within our affordability envelope and within the context of financial and system pressures.

Local Clinical Excellence Awards

In addition to basic pay, enhancements for out of hours and extra-contractual work, consultants in England are contractually entitled to have access to an annual Local Clinical Excellence Award scheme. In 2021 to 2022 approximately £450m (including employer national insurance and employer pension contributions) was spent nationally on LCEAs, with around £250m of that sum spent on consolidated awards awarded prior to 2018 and the remainder on new non-consolidated awards.

Having unsuccessfully attempted to reach collective agreement on a replacement LCEA scheme, from April 2022 new arrangements have come into effect which allow employers a significant degree of local flexibility to run their LCEA schemes to suit their own priorities. We are disappointed to note that, to date, it has not been possible to reach agreement with the trade unions on joint guidance to support employers to run their new schemes.

The arrangements now in place require employers to invest £7,900 award per eligible consultant annually into the award schemes. This funding covers consolidated (awarded before 2018) awards and new awards. We expect the sum spent on consolidated awards to continue to reduce over time as staff retire, leave the service or accept a National Clinical Impact Award, leaving a greater proportion of the funding available for new awards.

Even though there is no longer a national framework for awards, our ambition remains for local employers to increase and diversify the distribution of awards, effectively tackle issues of inequity and ensure engagement and participation is encouraged.

We understand that in the first year the new arrangements have been in place, the majority of employers have agreed with their Local negotiating committees not to run an awards round. Instead, most have agreed to distribute equally amongst eligible staff the funding which remains once the consolidated awards are paid out. The actual amounts received by staff will vary from Trust to Trust but will represent a supplement to consultant base pay.

In 2020 to 2021 and 2021 to 2022, in acknowledgement of pressures caused by COVID-19, the department approved requests from NHS Employers and the trades unions to distribute the funding equally as a one off non-consolidated payment to eligible consultants. However, our view remains that the purpose of LCEAs is to motivate consultants to achieve the highest levels of performance locally, contributing to the delivery of local priorities. Whilst we recognise the pressures coming out of COVID-19 which have impacted on capacity to run rounds, we are keen that in future award rounds are run annually in all employing organisations. We will continue to work with NHS Employers to support and encourage best practice and work towards this position.

In the 2022 report the DDRB asked for a breakdown of award holders by equality characteristics. There is currently no nationally held equalities data relating to award distribution for LCEAs. Data from the ESR is not of sufficient quality to easily and accurately distinguish the characteristics of new award holders from consolidated award holders at a national level. The guidance for the 2018 to 2022 scheme set the expectation that each local award committee would produce an annual report setting out details of award distribution by protected characteristic which would be shared with their remuneration board and Local Negotiating Committee. We would hope that updated scheme guidance, once it is finalised, will similarly encourage employers to collect such information and identify/act where improvements need to be made. However, at present there are no plans for this equalities data to be collated and analysed at a national level.

National Clinical Impact Awards

Within last year’s evidence we set out the rationale and summary of the reforms made to the National Clinical Excellence Awards Scheme. The reformed scheme has been re-named the National Clinical Impact Awards reflecting a deliberate shift in emphasis to the awards recognising the positive impact of NHS consultants’ work nationally.

The 2022 awards round is now underway, and we anticipate confirming outcomes to applicants in early 2023. The reforms have modernised the scheme and we remain committed to delivering on our policy aims of broadening access, making the application process fairer and more inclusive and rewarding and incentivising excellence across a wider range of work and behaviours.

While it is still too early to fully assess the impact of the reforms, we have seen positive signs in our provisional application data (see table 6.1) that more female and ethnic minority consultants are engaging with the scheme, and through the implementation of a new application portal, ACCIA hopes to report more accurately on the diversity of the scheme in future years.

Table 6.1: percentage of applications in 2021 and 2022 by gender and ethnicity

Year	Male	Female	Not stated	White ethnic groups combined	Other ethnic groups combined	Not stated
2021	69%	26%	2%	66%	33%	2%
2022	65%	33%	5%	61%	37%	2%

Table 6.1 sets out the aggregate percentage of applications by both gender and combined ethnic groups, across the 2021 and 2022 awards rounds. The table shows that the initial trends are positive, with the percentage of female and ethnic minority applicants increasing in 2022 compared to 2021. It is important to note that this is only showing numbers of applications, with success rates to be confirmed once the 2022 outcomes have been publicised.

The most recent, publicly available data on the scheme, including success rates by protected characteristic, can be found in the ACCEA annual report (which covers the 2021 awards round) and the next report will analyse the successes and areas for improvement following the first year of the reformed National Clinical Impact Awards (2022 awards round).

Our 2022 evidence also provided information on the agreed budget for the reformed awards over the next 5 years based on projected workforce growth (an increase of approximately 1% per annum).

Table 6.2: NCIA annual budgets between 2022 to 2023 and 2027 to 2028

Year	2022 to 2023	2023 to 2024	2024 to 2025	2025 to 2026	2026 to 2027	2027 to 2028
Scheme budget (£m)	127	128.5	130	131.5	133	134.5

The evidence noted that the award values will remain subject to the recommendations of the DDRB but asked that the DDRB allow the reforms to be fully implemented prior to making an uplift recommendation. We remain committed to the aim set out in the reform consultation of granting up to 600 new awards per year, and any uplift recommendation will require reprioritisation.

Specialty doctors, specialist doctors and associate specialists (SAS)

As members know, SAS doctors currently fall into 2 distinct groups; the first, doctors within the multi-year agreement (covering the period between 2021 to 2022 and 2023 to 2024) and therefore outside of the DDRB remit and the second being those doctors on closed contracts and included in the remit this year. Our evidence will articulate the challenges posed by this split in the SAS workforce and our concerns around the impact of pay between the 2 groups diverging.

The benefits of the multi-year agreement

As we outlined in evidence last year the jointly agreed 3-year deal invests an average of 3% per year of the deal. While the deal delivers improvements in pay progression (moving specialty doctors from an 11 point to a 5-point pay scale and progressing to the top 5 years faster) it is about more than just base pay. The deal focuses on enhancing career progression and the experiences of SAS doctors in the workplace. Highlights include:

• introduction of a new specialist grade, bridging the earnings gap between specialty doctors and consultants and increasing the basic earnings potential of the SAS workforce by up to 16% compared to the top of the specialty doctor grade
• introduction of safeguards and the SAS advocate role to improve health and wellbeing of SAS doctors
• an additional day of annual leave after 7 years’ service
• increases to the on-call availability supplement to create parity with consultants
• modernised terms and conditions through the adoption of the NHS staff handbook, for example, inclusion of enhanced shared parental leave

These changes are particularly important for the SAS grade who frequently report feeling undervalued in the workforce. The modernised contract is designed to improve the wellbeing and morale of SAS doctors. For employers, the deal improves flexibility to use staff resources in an affordable way that best supports service provision.

As members know, the deal and associated pay scale collectively agreed with the BMA was devised before the conclusion of the 2021 to 2022 pay round. The investment envelope of 3% per annum is in line with the funding level of other multi-year agreements. While we recognise that the economic context has shifted, both parties entered the agreement in the understanding that the pay and investment terms would be fixed for the full period and would not be modified to respond to external factors.

Challenges to implementation

In our evidence to members last year, we set out the challenges to implementing the 2021 specialty doctor contract. Our most recent data (August 2022) shows that 3,306 specialty doctors are employed on the 2021 contract compared to 6025 on the 2008 contract. Whilst overall uptake of the new specialty doctor contract is steady, this is largely driven by joiners from other grades or new joiners to the NHS rather than existing SAS doctors switching to the new contract. As the contract is not being favoured by the current cohort of specialty doctors, they will be missing out on the benefits highlighted above. We explained last year that the 3% uplift awarded to the 2008 closed specialty doctor contract in 2021 had impacted on the number of doctors wanting to transfer to the new terms. The conclusion of the 2022 to 2023 pay round and the uplift of 4.5% to the 2008 contract has compounded this issue.

Over the last year, including at the conclusion of the last pay round, we have worked with NHS England, NHS Employers, and the BMA to consider ways of incentivising increased transfer but have not been able to reach a satisfactory outcome.

The table below shows the current comparison of the 2021 and 2008 specialty doctor pay scales.

Table 6.3: comparison of 2022 to 2023 specialty doctor pay scales

Experience point	2021 contract 2022 to 2023 pay scale	2008 contract 2022 to 2023 pay scale	% gap 2008 to 2021	£gap 2008 to 2021
1	£50,373	£44,300	-12%	-£6,072
2	£50,373	£48,088	-5%	-£2,285
3	£50,373	£53,012	5%	£2,640
4	£56,906	£55,652	-2%	-£1,254
5	£56,906	£59,454	4%	£2,549
6	£58,756	£63,242	8%	£4,486
7	£64,237	£63,242	-2%	-£995
8	£64,237	£67,116	4%	£2,878
9	£64,237	£67,116	4%	£2,878
10	£71,654	£70,990	-1%	-£664
11	£71,654	£70,990	-1%	-£664
12	£71,654	£74,864	4%	£3,210
13	£75,361	£74,864	-1%	-£497
14	£75,361	£74,864	-1%	-£497
15	£75,361	£78,737	4%	£3,377
16	£75,361	£78,737	4%	£3,377
17	£75,361	£78,737	4%	£3,377
18	£78,759	£82,611	5%	£3,852

The table shows that the objective of increasing starting pay for new specialty doctors remains intact. Specialty doctors on the 2021 contract continue to earn more earlier in their careers, which helps to improve overall career earnings. However, for 10 of the 18 experience points pay is now 4 to 5% higher on the 2008 contract than the new 2021 contract.

If a similar approach is taken this year and the 2008 contract is uplifted by an amount higher than the average investment into the 2021 contracts, this will create a further divergence for the pay scales, particularly at the top of the pay scale. As an example, the table below shows the impact of a pay award to the 2008 specialty doctor contract 1% higher than average investment into the deal.

Table 6.4: illustration of 2023 to 2024 pay scale comparison of specialty doctor contracts where 2008 contract receives an award 1% higher than average investment into the deal

Pay step point	2021 contract 2023 to 2024 scenario	2008 contract 2023 to 2024 scenario	% gap 2008 to 2021	£gap 2008 to 2021
0	£51,000	£46,072	-10%	-£4,928
1	£51,000	£50,011	-2%	-£989
2	£51,000	£55,133	8%	£4,133
3	£58,756	£57,878	-1%	-£878
4	£58,756	£61,833	5%	£3,077
5	£58,756	£65,772	12%	£7,016
6	£65,500	£65,772	0%	£272
7	£65,500	£69,800	7%	£4,300
8	£65,500	£69,800	7%	£4,300
9	£72,500	£73,830	2%	£1,330
10	£72,500	£73,830	2%	£1,330
11	£72,500	£77,858	7%	£5,358
12	£80,000	£77,858	-3%	-£2,142
13	£80,000	£77,858	-3%	-£2,142
14	£80,000	£81,887	2%	£1,887
15	£80,000	£81,887	2%	£1,887
16	£80,000	£81,887	2%	£1,887
17+	£80,000	£85,915	7%	£5,915

As table 6.4 shows, if we continue with the approach taken over the last 2 years whereby the uplifts to the 2008 contract are higher than those agreed for the 2021 contract, we put the 2021 contract at a significant deficit to the 2008 contract.

We ask DDRB members to look ahead and consider the future position of the SAS workforce when making their recommendations. Given the 2021 specialty doctor is the only national contract open to new entrants, it is imperative that we protect the long-term appeal of that contract both in comparison to the closed contracts and to pay for other medical staff groups. It is important that we balance annual pay awards to the closed contract with the attractiveness of the new SAS contract. Whilst it remains the case that the new contract increases starting pay and earnings earlier in the career, these benefits are complex to communicate and often overshadowed by the simpler messaging of annual headline uplifts to the 2008 contract meaning fewer doctors see and understand the benefits of the new contract.

It is possible that the lower pay available at the top of the 2021 specialty doctor pay scale compared to the 2008 contract could impact on SAS doctors wanting to change roles. There is some anecdotal evidence of this occurring. If pay on the 2021 contract is not sufficient to attract staff movement and, as a result, employers struggle to fill vacancies, there is a risk that employers opt to use local contracts that mirror the 2008 pay scale as a workaround. The result would be the opposite of one of the key ambitions for reform - to reduce the number of contracts and therefore the variety of terms SAS doctors are employed on. This would also lead to an increase in locally employed doctors who may not necessarily benefit from the improvements envisaged for SAS doctors through the new national terms and conditions.

Specialist grade

As we set out last year, one of the main ambitions of reform was to improve career opportunities for SAS doctors. The specialist grade was created to deliver on that ambition, by providing an opportunity for progression for highly experienced specialty doctors. We are pleased that employers are creating specialist posts, our latest data from July 2022 shows that there are around 450 specialists (headcount) in the senior SAS doctor grades of a total of 2,266 published by NHS Digital for July 2022, see table 6.5 below.

Table 6.5 below shows the total number of associate specialists and specialists has grown by 5.3% between the introduction of the new grade and July 2022. Therefore, it appears that recruitment into specialist posts is more than making up for attrition from the associate specialist grade.

Table 6.5: number of associate specialists and specialists (headcount) March 2021 to July 2022

Month	Associate specialist and specialist headcount	% Change from March 2021
March 2021	2,151
April 2021	2,148	-0.1%
May 2021	2,135	-0.7%
June 2021	2,130	-1.0%
July 2021	2,123	-1.3%
August 2021	2,124	-1.3%
September 2021	2,154	0.1%
October 2021	2,159	0.4%
November 2021	2,179	1.3%
December 2021	2,185	1.6%
January 2022	2,193	2.0%
February 2022	2,219	3.2%
March 2022	2,232	3.8%
April 2022	2,211	2.8%
May 2022	2,240	4.1%
June 2022	2,251	4.6%
July 2022	2,266	5.3%

Source: NHS workforce statistics - July 2022 (Including selected provisional statistics for August 2022) - NHS Digital

We anticipate that the number of specialist posts will continue to increase as employers become more familiar with the role and the benefits it can bring for the workforce. The grade creates an alternative pathway for a career in medicine for senior clinicians, helping employers to recruit, motivate and retain highly experienced staff.

The longer-term future success and continued growth of the specialist grade will be largely underpinned by the attractiveness of the specialty doctor contract. To create the pipeline of highly trained doctors to take on specialist roles we need to ensure that doctors are first attracted to specialty doctor positions.

Doctors and dentists in training

The 2016 contract for doctors and dentists in training, following agreement with the British Medical Association junior doctor committee (BMA JDC) in 2019, is currently subject to a 4-year pay and contract reform deal. The 4-year pay deal ends in March 2023 therefore as set out in our remit letter we are looking for a recommendation for doctors and dentists in training for the 2023 to 2024 pay round.

This workforce, consisting of the foundation programme and core and specialty trainees, makes up the largest proportion of the medical workforce in England (approximately 49%), July 2022 workforce numbers show just over 63,000 FTEs, although many within this group will be ‘trust grade’ doctors on local contracts outside of an approved HEE postgraduate training programme. Between July 2014 and July 2022, the number of doctors and dentists in training (all grades) has increased by approximately 23.1%.

Upon completion of their training, doctors are eligible for consultant posts with high basic salaries. For example, a doctor that started training in 2012 to 2013 and progressed through training annually could see an increase of around 300% in 10 years; they would have been on a starting salary of £22,412, by 2022 to 2023 they could be joining the consultant workforce on a basic salary of £88,364.

Review of 2016 contract and multi-year pay deal

The 4-year deal was jointly agreed with the BMA JDC in 2019, covering the period from the year 2019 to 2020 to the year 2022 to 2023. The 2016 contract and 4-year pay deal have significantly improved pay and terms and conditions. They introduced important contract reforms, both in 2016 and 2019, such as changes to safety and rest limits and improved support for those training less than full-time, to modernise the national contract.

As a result of the deal, all existing pay point values will have increased by a cumulative 8.2% by the deal’s completion. Total investment was around 3% higher (11.5%) and the majority of this additional investment (about 2.5%) was for the creation of the new top pay point, nodal point 5.

Nodal point 5 was implemented in October 2020 and has significantly increased what doctors in training could have expected to earn had the new higher pay point not been introduced. Doctors in training reaching nodal point 5 can expect a 14% higher basic salary than nodal point 4. In 2022 to 2023, nodal point 5 increased to £58,398 and currently around 8% of doctors in training and trust grades doctors benefit from being on this higher pay point.

Table 6.6: basic pay scale and estimated average total earnings for a full-time equivalent by 2016 contract nodal point

Pay point	Stage of training	2022 to 2023 basic pay	2022 to 2023 Estimated average total earnings for a full-time equivalent*
Nodal point 1	FY1	£29,384	£37,800
Nodal point 2	FY2	£34,012	£45,100
Nodal point 3	ST1 - ST2	£40,257	£53,300
Nodal point 4	ST3 - ST5	£51,017	£67,500
Nodal point 5	ST6 - ST8	£58,398	£77,100

*Total earnings calculated based on average additional earnings as a % of basic pay by grade using internal DHSC management information for 2021 to 2022. Values are rounded.

A number of other pay and non-pay improvements were agreed for the 2016 contract and represent an investment of approximately £90 million on top of the investment into basic pay awards. These improvements included:

• increased allowances for those working the most frequently at weekends, with those working 1 weekend in 2 receiving a 15% top up
• increased rates of pay for night shifts that finish after midnight and by 4am, where the entirety of the shift will attract an enhancement of 37 per cent of the hourly basic rate
• the creation of a permanent allowance of £1,000 a year - on top of their usual pay - for doctors who work less than full time, to recognise the additional costs they face training less than full time

We do not hold data on the trends on average working hours for doctors and dentists in training. However, the 2016 contract pays for every hour worked (should additional hours be worked) and pays an additional supplement on top of basic salary for weekends worked, increasing as weekend frequency increases.

Impact of COVID-19 on training

COVID-19 led to significant changes and disruptions to medical education due to loss of teaching time and placements. COVID-19 disrupted the well-established, traditional structure of medical and dental education impacting trainee recruitment, rotation, assessment, and progression. However, it also led to the development of new innovations, such as accelerating the development of online learning, introduction of novel ways of student assessment, simulation software, remote consultations, changes to clinical assessment, and repurposing elective periods.

Intake numbers for medical students increased, to 8,405 in 2020 to 2021 and 8,460 in 2021 to 2022, as a result of disruptions to A-level assessments. This was significantly above the planned expansion cap of 7,500. These innovations now form valuable options in the delivery of undergraduate medical and dental education, together with work to find the necessary additional placement capacity in the NHS.

COVID-19 had a significant cumulative impact on the postgraduate medical and dental training pipeline, where doctors in training were redeployed to COVID-facing settings, or had elective learning opportunities cancelled. The department and its system partners established the post graduate medical education (PGME) Training Recovery Programme to reset, recover and reform postgraduate medical education. Necessary interventions have been effective, to ensure progression at each stage of training and avoid congestion to the training pipeline. Without targeted interventions, there was a risk that congestion would have led to significant costs to the system, discontent and attrition in the junior medical workforce, and ultimately a risk to the supply of consultant, GP and SAS doctors.

As a result of COVID-19, all non-emergency dental treatment was initially paused. There were ongoing issues, such as the requirement to use aerosol generating procedures in dental clinics in compliance with COVID-19 guidance, which prevented dental services to resume at pre-COVID-19 levels. This resulted in a backlog of patients and had an impact on undergraduate dental students across England - particularly the placement time of these students. Most procedures are aerosol generating and required social distancing, plus students undertake a lot of open plan lab-based work. This affected the capacity for students to have clinical experience at the level they had before COVID-19.

To enable medical and dental schools to catch up on final years students’ placements and ensure the maximum number of graduates and for those already in postgraduate medical training, we provided HEE with £30m in 2021 to 2022 to support the development of individual training recovery plans. In 2022 to 2023, we provided an additional £25m to address the continued impact of the COVID-19 on doctors and dentists in training and their educators.

Due to this additional support HEE reported that extension rates are lower compared to 2019 to 2020. As COVID-19 ensued, up to 50% of trainees’ progression was identified as being at risk in 2020. At the start of the 2021 to 2022 academic year, 14% of trainees were identified at risk. By 2022 to 2023 this figure is estimated at 3% of trainees identified at risk of COVID dependent delay.

HEE have introduced a number of measures to mitigate the impact of COVID-19 on training progression, including refining the annual review of competence progression (ARCP) panels, looking at minimum curriculum requirements, identifying where compensatory evidence can be used, defining critical progression points, and introducing new ARCP outcomes.

ARCP outcome 10.1 and 10.2 are no-fault outcomes which recognise that progress of the trainee has been satisfactory but that acquisition of competences or capabilities by the trainee has been delayed by COVID-19 disruption.

Outcome 10.1 is used where trainees are not at a critical progression point, allowing them to progress to the next stage of training where they can obtain the relevant competences or capabilities.

Outcome 10.2 is used when a trainee is at a critical progression point in their programme and there has been no derogation to normal curriculum progression requirements given by the relevant medical royal college or faculty. This means that additional training time is required before the trainee can progress to the next stage in their training, or obtain the certificate of completion of training (CCT).

The 2016 contract for doctors and dentists in training links pay points to the level of training. Therefore, where an outcome 10.2 prevents a trainee from moving to the next stage of training, it may impact progression to the next pay point. The BMA and NHS Employers have agreed and published joint guidance that sets out measures to address the career earnings impact for outcome 10.2 recipients when they commence in consultant posts. The intention is to use flexibilities within the 2003 terms and conditions - consultants (England), so that where additional training time is required due to COVID-19 delays, this should be recognised by amending the starting consultant pay point.

Postgraduate training fill rates

Recruitment into specialty training remains competitive with over 45,000 applications across UK training programmes in 2022 to 2023 compared to 40,000 in 2021 to 2022. The below table provides an overview of applicants by their country of primary medical qualification (PMQ). This highlights an increase in overseas applications seen since the introduction of the health and care visa in 2020.

Table 6.7: postgraduate training fill rates between the year 2020 to 2021 and the year 2022 to 2023

Recruitment year	UK	EU	Rest of World	No qualification (public health)
2020 to 2021	47.68%	6.30%	44.71%	1.31%
2021 to 2022	46.66%	6.04%	44.81%	2.49%
2022 to 2023	40.40%	6.82%	50.37%	2.40%

In 2020 to 2021, the first year of core/specialty training saw a 99.75% fill rate, with 8,497 posts filled out of a total of 8,518. This included successfully meeting the GP manifesto target of 4,000 acceptances.

In higher specialty training, fill rates remain generally strong, with an overall fill rate of 87%. However, a number of specialties such as palliative medicine, genito urinary medicine (GUM), paediatric and perinatal pathology require remedial action due to low fill rates in recent years. This could include financial recruitment incentives and review of person specifications eligibility criteria.

Flexible pay premia (FPP), targeted enhanced recruitment scheme (TERS) and foundation priority programmes

The DDRB has asked the stakeholders for evaluations of the various financial initiatives in place, including flexible pay premia (FPPs) in England, targeted enhanced recruitment scheme (TERS) in England, and foundation priority programmes in England. It is important the department’s evidence in these areas is read in conjunction with the evidence from HEE who retain responsibility for recruitment to training posts.

FPPs are a form of recruitment and retention payment unique to the 2016 contract, designed to support recruitment to certain ‘hard to fill’ specialties and training programmes, as well as to ensure certain career pathways, such as academia and dual qualification in oral and maxillofacial surgery, are not disincentivised due to their earnings potential or training requirements.

FPPs are currently worth between £2,789 and £9,144 per year under specific conditions. Full details on the value of these payments and who is eligible to receive them are available via the latest medical and dental pay circulars available from NHS Employers.

Pay is not the only factor influencing choice of specialty. HEE data shows improvement in fill rates of specialties that have an FPP between 2018 and 2022 although there may be other drivers that are contributing to the improvement in fill rates other than the FPPs.

HEE have published acceptance and fill rates for specialty training positions starting in August 2022. The latest publication gives more granular detail than previous publications. This is useful for identifying impacts on specific training specialties. However, it makes comparison to previous data more difficult. There has been expansion in medical supply from rising levels of international recruitment which has helped to fill posts, the effects of which we would not be able to split out from the FPP impacts.

It is hard to evaluate the success of FPP type payments without fully understanding the reasons that trainees chose their specialties, and the choices they would have made had the FPP not been available. A whole system perspective of ensuring appropriate recruitment/supply to all specialties as part of the workforce strategy also needs to be considered.

Table 6.8 shows August 2022 fill rates for each of the specialties where a FPP applies. general practice, psychiatry core, emergency medicine & histopathology all have fill rates over 90%. However, higher specialty training in psychiatry has a relatively lower fill rate at 82.8% and oral & maxillofacial surgery has the lowest 60% fill rate (though also has a relatively low number of posts compared to other specialties).

Table 6.8: summary of all specialty training programmes with FPP

Training programme	Posts	Accepts	Fill rate %
General practice ST1-4	3625	3648	99.9
Psychiatry core ST1-3	406	402	99.0
Psychiatry higher ST4+	314	260	82.8
Emergency medicine ST4+	51	50	98.0
Oral & maxillofacial surgery ST3+	20	12	60.0
Histopathology ST1+	113	104	92.0

Where there are multiple different FPP specialty programmes under the same specialty grouping the following figures 2 and 3 show the breakdown of fill rates by training programme.

Table 6.9 outlines the fill rates across the higher specialty training in psychiatry specialties. The lowest fill rates in the psychiatry of learning disability, and psychiatry of learning disability and child and adolescent psychiatry, both less than 40%.

Table 6.10 outlines the fill rates across the histopathology specialties. Diagnostic neuropathy has a 28.57% fill rate of a total of 7 posts. 0 out of 4 posts in paediatric and perinatal pathology were filled.

Table 6.9: higher specialty training in psychiatry breakdown

Speciality	Posts	Accepts	Fill rate %
Child and adolescent psychiatry ST4	44	38	86.4
Forensic psychiatry ST4	19	19	100.0
Forensic psychiatry and medical psychotherapy ST4	1	1	100.0
General psychiatry ST4	123	112	91.1
General psychiatry and old age psychiatry ST4	41	41	100.0
General psychiatry and medical psychotherapy ST4	8	7	87.5
Medical psychotherapy ST4	1	1	100
Old age psychiatry ST4	46	29	63.0
Psychiatry of learning disability ST4	28	11	39.3
Psychiatry of learning disability and child and adolescent psychiatry ST4	3	1	33.3
Total	314	260	82.8

Table 6.10: Histopathology breakdown

Speciality	Posts	Accepts	Fill rate %
Chemical Pathology ST3	5	5	100.0
Diagnostic neuropathology ST3	7	2	28.57
Histopathology ST1	97	97	100
Paediatric and perinatal pathology ST3	4	0	0
Total	113	104	92.04

The full breakdown of all specialties is published by HEE: Specialty recruitment: round 1 - acceptance and fill rate.

In addition to the FPP payment, GP trainees may also be able to access the targeted enhanced recruitment scheme (TERS) which offers GP trainees a one-off payment of £20k to commit to working in areas that have been hard to recruit in for the past 3 years. This scheme is led by HEE and is separate to the 2016 contract.

The areas assisted by TERS GP training recruitment have achieved 99.6% recruitment. It would appear the scheme was a strong success in increasing recruitment. It is hard to give details of the success of the scheme without understanding the driving factors for the trainees who accepted these posts and their career choices had the scheme not been available. Pay and non-pay related factors attract trainees to specialties and regions and these are very important to consider when assessing the use of financial incentives.

From April 2023 Health Education England and NHS Digital will become part of the new NHS England that will bring together the 3 organisations to create a smaller, simpler high performing organisation that leads the health service more effectively.

The new NHS England brings education and training spending into NHS England’s funding allocation and simplifies NHS national leadership creating greater synergy across the Long-Term Plan, NHS People Plan, education and training reform, and workforce transformation.

Creating a new single national and regional leadership organisation will create better alignment of service, financial and workforce planning, and better support the NHS to recruit and develop the health professionals needed to deliver exceptional patient care, now and in the future.

Following the review of the UK Foundation Programme, HEE launched a range of foundation priority programmes from August 2019 to support specific areas of the UK that have historically found it difficult to attract and retain trainees through the foundation and specialty recruitment processes. HEE’s main objective is to maximise the opportunities for applicants who wish to be in less popular areas and consequently improve supply for specialty training and beyond. These include:

• 85 priority programmes at the Northern Foundation School with an offering of a £7,500 incentive per training year, plus additional online education package for all Foundation doctors
• inclusion of fellowships with Royal Colleges of Psychiatry and Pathology, supporting recruitment to Core Psychiatry and Pathology specialties

Actions to improve trainee experience

The enhancing junior doctors’ working lives (EJDWL) programme was established in 2016 to address the concerns and improve the working lives of doctors in training. Led by Health Education England (HEE), it is a cross-system collaboration to drive and deliver system improvements and meaningful change to postgraduate medical training. The programme includes initiatives such as, reforming study budgets, study leave and delivering greater flexibility in medical training.

In July this year, HEE published their annual review of this work for 2021-2022. Key updates from this work include the following outcomes:

• flexible training

  • all doctors in postgraduate training can now apply to train on a less than full time basis

  • HEE aims to support those doctors taking time to make career and training choices. The recognition of experience completed outside of training programmes enables a more efficient training pathway, a reduction in costs and enhances the rate of senior workforce provision

• recruitment

  • adaptation of processes following COVID-19 has enabled HEE to optimise the use of technology, while the use of statistical analysis ensures equality, diversity and inclusion are fully considered

• improving the quality of training

  • HEE has created the first NHS-wide patient safety syllabus which will result in NHS employees receiving enhanced patient safety training

EJDWL continues to be an important focus of HEE’s work. The programme aims to enable doctors to progress in their training and longer-term medical careers whilst maintaining a healthy and balanced personal life.

Locally employed doctors

In their last report the DDRB asked for further information on how many doctors are on locally employed contracts, what roles they play in hospitals, why they are on local contracts and how their terms and conditions vary from those on national contracts. The department does not determine the pay, terms and conditions of NHS staff on local contracts and therefore has not asked the DDRB for a recommendation in respect of locally employed doctors. However, we recognise and share the DDRB’s interest in understanding more about this group. We understand that most locally employed doctors are in arrangements where their pay is uplifted annually in line with comparable workforces on national contracts, for a small number of others it is ultimately for local employers to determine their uplifts.

There are a variety of reasons why doctors are employed on local contracts and are therefore not a homogenous group. For example, some are junior doctors who step out of training, either after foundation training to help decide which specialty they wish to pursue or further into to the training programme to pursue other interests or take a break from the pressure of examinations. Others may be international doctors in their first post prior to taking on a longer-term role. In recent years there was also an increase at the associate specialist level in the absence of a national senior SAS contract which has now been resolved.

The information we currently hold on the actual terms and conditions used for locally employed doctors is relatively limited. We understand that there are a range of employment models in use but the majority mirror current or closed national contracts. For example, some organisations use the 2016 contract for junior doctors as a template to create a set of local terms and conditions for doctors outside of an official training programme. Others employ doctors on terms similar to the 2002 contract for junior doctors. This is an area we wish to explore further so we can better understand why employers use local terms and conditions, why they select particular elements of the current and closed national contracts for their local arrangements and why other elements are not utilised.

It is difficult to gain a completely accurate picture of the numbers of locally employed doctors due to the different employer practices in using ESR codes. However, Table 6.11 below uses an analysis of ESR data from July 2022 to set out the proportions of doctors in various contractual arrangements.

Table 6.11: doctors split by contact type (July 2022)

Month	Category	Grade	% of workforce	Number
July	Open contracts	Consultant contracts	39%	59,368
		Specialty doctor contract	2%	3,130
		Specialist doctor contract	0%	445
		Junior doctor	34%	51,503
		GP/dental educators	1%	1,144
	Other contracts linked to national terms and conditions in medical pay circular	closed grades	13%	20,039
		Open - trust grades (LEDs)	6%	9,758
	Others	Other (not recognised)	4%	5,376

This table shows that the significant majority of staff are employed on open national contracts or national contracts which are closed to new entrants. Staff in the final 2 rows of the above table (amounting to 10% of the total) would be classed as ‘locally employed’ doctors, also often referred to as ‘trust grades’ or ‘clinical fellows’.

In relation to how pay is determined, locally employed doctors fall into 2 main groups. According to the above data most are employed on contracts which mirror the pay scales linked to national terms and conditions (marked in table 6.9 as Open - Trust Grades (LEDs)). For these doctors pay is uplifted annually in line with those on comparable national contracts. So, for example, for locally employed doctors on contracts mirroring the 2016 junior doctors’ contract, pay will have been uplifted by 2% from April 2022 to keep pay in line with those on national contracts. As NHS Employers will set out in their evidence, employers are strongly encouraged to place their locally employed doctors on these types of arrangements to ensure parity of treatment in relation to pay.

However, some employers do use other pay and employment arrangements. The above table shows that there is a small number of doctors (approximately 4% of the total) who are on alternative grade codes which are not recognised as mirroring the national contracts. We do not have information relating to how their pay and any uplifts are determined.

Ultimately, it is for employers to determine the employment arrangements for locally employed doctors and a degree of flexibility has value in certain circumstances. However, we would expect that all doctors, regardless of how they are employed, are treated fairly by their employer. It is vitally important that all doctors, no matter their contractual arrangements or grade, are treated as part of a team, appropriately rewarded and respected for the contribution they deliver.

General dental practitioners

Dental system reform  

Access to dentistry was severely impacted by COVID-19. The government provided unprecedented financial support to the sector during this time to ensure that practices remained viable and able to offer treatment during the COVID-19 pandemic and beyond.

With NHS dentists operating at below 100% capacity for over 2 years, many people have not been able to regularly access a dental professional. We are taking action to address this, in a way which is fair for patients, dentists and the taxpayer.

Since 2021, the NHSE and the department have been working closely with the sector, including the British Dental Association, to develop a package of improvements to reform the wider dental system. The improvements were announced in July 2022 and included changes to ensure dentists are remunerated for more complex work and patient access is improved, especially for those with higher oral health needs.  

Improve care for high needs patients:

We have responded to the call from dentists to improve the remuneration system to incentivise complex preventative and restorative treatment. We have made changes to the way dentists are remunerated for the range of treatments that are currently covered in band 2 treatments. Dentists will be paid more when they need to do 3 or more fillings or extractions and provide endodontic care. See more information on the first stage of dental reform on the NHS website.

To provide the capacity to deliver the additional care required by higher needs patients, we will support practices to adhere more closely to the National Institute of Clinical Excellence guidance on recall intervals which indicate that a healthy adult with good oral health need only see a dentist every 2 years and a child every 1 year. We want to decrease the volume of any low value clinical care provided through NHS dentistry, for the NHS and patients themselves.

These changes will support dentists and patients in getting the care they need as we tackle the COVID-19 backlogs in care.

Promote more effective use of skill mix

Dental care can be provided by a wide range of dental professionals including dental nurses, dental hygienists, and dental therapists. We have made it clear that there is no legal barrier to the increased use of these professionals in the provision of NHS care, and seek to increase their use in the provision of NHS care, as is already the case in private practice. NHS England will issue clear guidance on how to utilise these team members to provide NHS care that is within their scope of practice and which they have the skills, competence and experience to deliver safely and effectively in the best interests of patients. We are working with the NHS Business Services Authority to make sure there are no administrative barriers to more effective use of this skill mix in practices providing NHS care.

This will help improve access to NHS care and make dental care professional roles including dentists more fulfilling and rewarding and help to tackle workforce challenges in underserved areas.

Maximise patient access from available dental resources

NHS England will work with local commissioners to help ensure that dentists are able to deliver high quality care to patients. Most dental practices consistently deliver their contracted amount of dental activity, but there are some that do not, and some that want to deliver more NHS dentistry.

We want to enable high performing practices to expand to deliver more NHS care, particularly in those areas where NHS dentistry is less prevalent. To incentivise this, we will enable, subject to commissioner agreement, practices to deliver up to 110% contracted activity.

Where contractors are unable to deliver their contracted activity in year or persistently across years, commissioners are currently limited in their ability to recommission that activity to contractors better able to do so. In the 2019 to 2020 year, 13% of contractors had consistently failed to deliver. This lost activity represents around 4.6 million Units of Dental Activity per annum.

As an initial step, NHSE will encourage commissioners and contractors to work together so that where a practice has not delivered 30% of contracted activity by mid-year, 10% of annual activity will be rebased with agreement of the contractor. For contractors that consistently do not meet their targets over a number of years, we will enable NHSE to rebase contracts to achievable levels and release unused funding to commission care from other providers.

Improve communication with patients

We know that many patients have experienced difficulty finding an NHS dentist, in part because of the limited information on the NHS website. We will make the updating of the NHS website a contractual requirement for dental practices. This will make it easier for patients to find a dentist who can deliver the care they need and for the system to refer patients to practices with capacity.

Recruitment of dentists

International professionals form a large proportion of joiners to the General Dental Council (GDC) register. They are a vital part of the UK’s dentistry workforce, ensuring that there is more capacity for dental treatment than UK graduates can provide alone.

As part of the ongoing reforms to healthcare professional regulation, we have identified and amended prescriptive detail which restricts the GDC from modernising its international registration processes. The department is working with the GDC to:

• support flexibility for the GDC to ensure that international processes are proportionate and streamlined, whilst continuing to robustly protect patient safety
• enable the GDC to increase the number of overseas registration exam (ORE) seats it offers by charging a fee which covers the cost of the exam, explore alternative ORE providers, and make changes to the structure of exam and applicant information which will support an increased pass rate
• allow the GDC to explore alternative pathways to international registration, such as recognition of programmes of education delivered outside the UK, or registration based on recognition of the qualification held by an applicant, as it considers appropriate

Current arrangements ensure that UK regulators continue to automatically recognise relevant European Economic Area (EEA) qualifications of healthcare professionals, including dentists. This enables qualified dentists from other EEA countries to continue to practise in the UK and we want to continue to facilitate their vital contribution to the dentistry workforce. EU Exit legislation places a duty on the Secretary of State to carry out a review of the operation of these provisions at the start of 2023. The system of automatic recognition will not terminate unless further legislation is made to bring the current system to an end.

Alongside the July 2022 changes, which are already being delivered, the department continues to work with NHS England and the dental sector on further improvements, with a particular focus on access to urgent care and further workforce and payment reform. These are due to be announced in 2023.This will build on previous analysis around payment models, which have been cited as a major concern in the sector, for example by the BDA. There are advantages and disadvantages to all payment models. We will continue to work with stakeholders to understand the issues and concerns and this includes considering what reform might be needed to the remuneration model. There is no perfect system and careful consideration would need to be given to any potential changes to the complex dental system so that we deliver a system better for patients and the profession.

We understand that the DDRB requested further information on financial recovery for undelivered activity. NHSE are best placed to provide this information given their role in NHS dental commissioning.

General medical practitioners

Earlier chapters in this year’s evidence include further detail on general medical practitioners, including workforce strategy, recruitment and retention, and earnings. This section looks specifically at the implementation of the 5-year GP contract.

Implementation of the multi-year GP contract agreement

In January 2019, the government, NHS England and the GPC of the BMA agreed to the most ambitious GP contract in recent years. The resulting 5-year framework for GP contract reform implements the commitments set out in the NHS LTP and is underpinned by a record level of additional investment in primary and community care (an extra £4.5 billion by the 2023 to 2024 year). The aim of the framework was to provide greater financial security and certainty for practices. It has seen billions more invested in improved access, expanded services at local level, and the development of PCNs, which were launched in 2019. In 2020, at least £1.5 billion was committed in cash terms for GPs until 2023 to 2024 for additional staff, on top of the £4.5 billion previously committed.

In our previous written evidence to the DDRB, the department set out the contractual easements and additional funding that were provided to relieve pressure on GPs and free up general practice capacity to support in the response to the COVID-19 pandemic. It also set out the phased approach the government took to introducing changes to the GP contract in 2021 to 2022 in recognition of the pressures on general practice from COVID-19.

After consultation with the BMA’s general practitioners committee England (GPC), on 1 March 2022, NHS England published in a letter the updates to the contract arrangements from 1 April 2022. These contract changes for 2022 to 2023 represent the fourth year in the 5-year framework for general practice. The contract changes support a focus on long-term condition management and chronic disease control, timely access for patients with urgent care needs and the wider NHS LTP prevention agenda. The changes also introduced the new arrangement for extended access services (access to GP services outside of core GP practices hours) which aims to remove variation in existing extended access services across the country and provide a more consistent offer for patients.

A further letter was published on 26 September 2022, setting out measures to support the expansion of general practice capacity and reduce both workload and administrative burden. These measures included changes to the network contract direct enhanced service to introduce further flexibility into the ARRS including the addition of a GP assistant role to help reduce administrative burden for GP teams, and retiring or deferring some investment and impact fund (IIF) indicators worth £37m, and allocating this funding to PCNs via a monthly PCN capacity and access support payment for the purchase of additional clinical services or workforce to increase access to core services this winter.

7. Total reward

Introduction to total reward

Pay makes up one part of the overall reward package, and whilst important, there are other benefits which have both financial and non-financial value and impact the motivation, recruitment, and retention of the NHS workforce and should therefore be considered by the DDRB.

The total reward package in the NHS is generous, with non-basic pay making up a significant part of total reward, approximately 40% for consultants.

The reward package includes a generous holiday allowance, which goes up to 33 days annual leave per year on top of public holidays, sickness absence arrangements, of up to 12 months of payment - well beyond the statutory minimum, access to a defined benefit pension scheme with an employer contribution rate of over 20%, enhanced parental leave, and support for learning, development, and career progression. These benefits are above the statutory minimum and exceed those offered in other sectors. Comparisons with the wider labour market should not just be limited to pay but include the full reward package.

DHSC has made a number of changes in the last year which are likely to have a positive impact on the reward package for doctors and dentists in the NHS. These include reforms to pension contributions, new retirement flexibilities, and measures to support clinicians impacted by pensions tax to continue to deliver their NHS work.

Over the last year, NHS England and NHS Employers have furthered their guidance to employers to develop packages which support the recruitment, retention and motivation of staff.

Measuring the value of the package

The department commissions the Government Actuary’s Department (GAD) to measure the value of the total reward package for a range of medical roles, as shown in Chart 7.1 below. The elements included in the package are basic pay, annual accrued pension, additional annual leave, Clinical Excellence Awards, an average of one extra session, additional sick leave, out of hours/on call payments, weekend allowances and study leave.

Figure 7.1: value of the wider reward package for NHS doctors

The department also commissions GAD to provide analysis of the trend in wider reward for doctors over time. Chart 7.1 looks at the split of total wider reward packages between basic and other pay on 30 September 2020, 30 September 2021 and 30 June 2022. GAD believes this is appropriate and will only cause a negligible difference for the purpose of comparison. This is also consistent with the approach used in previous years and reflects the availability of the relevant data.

It is however important to note that the Basic Pay definition used by GAD for the analysis this year is mean annual basic pay per person, whereas in previous years the definition used was mean annual basic pay per FTE. To make the comparisons consistent, GAD have updated the analyses over 2020 to 2021 and 2021 to 2022 so that the Basic Pay definition is also based on mean annual basic pay per person rather than FTE. As a result of this, there is a slight reduction in the average consultants’ pay award as the basic pay per person is typically lower than the basic pay per FTE.

The chart shows that all the doctor roles considered have experienced an increase in total wider reward over the period. F2 doctors and SPR doctors experienced broadly consistent increases of 2% in each year over the period, meaning total reward increased by around 4% overall. In 2022 to 2023, the value of the reward package for consultants with 14 years seniority increased by 4% compared to the previous year, resulting in a total rise over the whole period of 7%. The value of the reward package for average consultants increased by around 3.5% in 2021 to 2022 and by around 2.4% in 2022 to 2023, resulting in a total increase of 6% over the period between 2020 to 2021 and 2022 to 2023. All doctor roles considered have at least 37% of the total reward made up of non-basic pay.

Figure 7.2: wider reward trend for NHS doctors, between 2020 to 2021 and 2022 to 2023

GAD also provide analysis of reward across various NHS doctor roles and private sector occupations. This is designed to give an approximate indication on how wider reward between roles and occupations change over time and not intended to provide a direct comparison between any direct doctor role and other occupation. This is largely due to the availability of data and difficulty between drawing appropriate comparisons with any one NHS role and other roles.

As with the trend analysis above, the basic pay definition used for the analysis this year is mean annual basic pay per person, so the 2012 to 2013 analysis has also been updated for consistency. As a result, there is a reduction in the average consultants’ pay award as the basic pay per person is typically lower than the basic pay per FTE.

The chart shows that non-basic pay makes up a larger proportion of NHS total rewards across all roles analysed relative to private sector occupations, with this making about 40% of consultant rewards. The chart also shows that that the professional occupations in the private sector considered experienced an increase of around 18% in reward between 2012 and 2021, whereas the managerial roles in the private sector experienced a slight decrease by 1%. For the doctor roles considered, the value of reward packages increased by around 11% for F2 doctors over this period, around 31% for SPR doctors, and around 13% for average consultants. The large increase for SPR doctors may be driven by an increase to basic pay following the new 2016 doctors in training contract.

Figure 7.3: wider reward trends for NHS doctors relative to private sector roles, 2012 to 2013 and 2021 to 2022

Enhanced parental leave

As well as the total reward elements included in the analysis above, NHS staff with 12 months continuous service with one or more NHS employers are also entitled to maternity benefits above the statutory entitlement. GAD estimate that a doctor earning £55,000 would be entitled to earn maternity pay of around £12,000 more than that they would be entitled to under the current statutory maternity pay (SMP) allowances.

This estimate is provided for illustrative purposes only and represents the additional value of NHS staff entitlement in excess of SMP. Maternity pay for doctors depends on the member’s contractual entitlements and is calculated relative to the current statutory maternity pay entitlements.

Other benefits

Other than the national reward elements included in the above analysis, employers have the flexibility to enhance their local reward package, and many offer a range of benefits and discounts which have financial value to staff and may support recruitment and retention of staff and improve employee engagement.

Although the range of benefits offered varies across employers, some popular flexible benefits can include salary sacrifice schemes, options to buy and sell annual leave and a range of discount vouchers, including the Blue Light Card which is available to all NHS staff at a cost of £4.99 for 2 years. Some employers also offer travel benefits such as season ticket loan and cycle to work scheme, as well as health and wellbeing benefits including discounted gym memberships. Many trusts have also partnered with third party providers offering staff up to 20% discount on shopping, insurance, and travel. Staff may also be entitled to cashback on purchases at specified retailers using prepaid cards.

The overall value to staff can vary depending on the specific benefits options offered across employers and the level of benefits taken up but we estimate these additional flexible benefits could be valued up to 1% - 3% of basic pay on average across NHS employees.

Employers are stepping up this support to make benefits go further. NHS Employers has developed guidance to support employers when offering benefits to mitigate higher living costs and to highlight what is available. These benefits can include:

• housing and utilities - rental deposit schemes, home electronics salary sacrifice scheme, accommodation and rent subsidies
• childcare - subsidised childcare, on-site nurseries, government tax free child support scheme
• travel - free parking, transport season ticket loans, public transport subsidies, pay expenses weekly
• food and leisure - free or subsidised meals on site, signposting to emergency service discount sites, access to free sanitary products
• other financial support - saving schemes, will writing services, financial education workshops, budget planning guidance, early access to pay.

Flexible working

As a strong driver of retention, it is important to many NHS staff to have the opportunity to work flexibly, regardless of role, team, organisation, grade, or reason. ‘We work flexibly’ is one element of the people promise, which the NHS is committed to delivering for staff by 2024 to 2025.

The ambition is that all NHS staff should be offered the chance to work flexibly. This won’t happen overnight and it’s not always straightforward to accommodate all individual work preferences, but becoming a more flexible, modern employer in line with other sectors is vitally important and is key to retaining our existing staff and attracting new people into the NHS workforce. Flexible working is about more than just retention. It can unlock new opportunities and contribute to improving people’s mental health, wellbeing and engagement with their role.

NHSE have developed a range of flexible working interventions and resources nationally to support local organisations to adopt flexible working practices across their organisations. These include:

• a published flexible working definition and set of principles for all staff
• publication of 2 toolkits to support line managers in leading flexible workplaces for all and to help staff to prepare for positive conversations in requesting it
• proactive work with several organisations to review their approaches to flexible working and to encourage implementation
• development of a simple cost calculator to help organisations identify potential cost savings by calculating turnover, recruitment and bank and agency expenditure
• support to organisations in the implementation of effective use of e-rostering systems, accelerating roll-out where possible
• NHSE also encourages employers to implement the working carers passport to support timely, compassionate conversations about what support including flexible working arrangements would be helpful

The NHS Pension Scheme

The NHS Pension Scheme remains a valuable part of the total reward package available to doctors and dentists and is one of the best pension schemes available.

Eligible doctors and dentists will now belong to one of the 2 existing schemes, both of which are defined benefit schemes. The final salary scheme, or legacy scheme, is made up of the 1995 and 2008 Sections and is now closed to new members. All new staff join the 2015 Scheme, a career average revalued earnings (CARE) scheme which provides benefits based on average earnings over a member’s career. Benefits in the 1995 to 2008 Sections for self-employed doctors and dentists (practitioner members) are also calculated on a CARE equivalent basis. The key differences between the 2 schemes, other than the way benefits are calculated, are different normal pension ages and accrual rates, as shown in the table below.

Table 7.1: comparison of scheme, retirement age and accrual rate

Scheme or Section	NPA	Accrual rate
1995 Section	60	1/80th
2008 Section	65	1/60th
2015 Scheme	State Pension Age	1/54th

The 2015 Scheme was introduced as part of wider reforms implemented by regulations made under the Public Service Pensions Act 2013. As part of these reforms, public service pension scheme members within 10 years of retirement were originally given transitional protection, and so remained in their legacy pension schemes. In December 2018, the Court of Appeal found this protection to be discriminatory against younger members. This has become known as the ‘McCloud judgment’. The government accepted the judgment applies to other public service schemes, including the NHS, and has set out how the discrimination will be remedied. This is known as the ‘McCloud remedy’.

GAD calculates that Scheme members can generally expect to receive around £3 to £6 in pension benefits for every £1 contributed. GAD also estimates that a doctor with membership wholly in the 2015 Scheme, progressing to be a consultant and retiring at Normal Pension Age, can expect an annual pension of around £63,000 in today’s earnings terms. A GP partner can expect an annual pension of around £66,000 and a salaried GP an annual pension of around £47,000.

It is important to note that this estimate assumes that the example member works full-time without any part-time working or career breaks. However, this figure would suggest that members who choose to work part time during their career or make use of the new retirement flexibilities set out later in this document can still expect to receive a good level of income in retirement, as measured against the Retirement Living Standards as published by the Pensions and Lifetime Savings Association, especially when combined with their State Pension entitlement.

The estimates allow for the deduction of scheme pays debits where annual allowance/lifetime allowance charges have been incurred. In line with the Autumn Budget, it is assumed that the lifetime allowance limits will be frozen until 2025. Thereafter, it is assumed that the limits will be indexed with general earnings increases. It is important to note that GAD previously worked in net rates and implicitly assumed that the limits were indexed with CPI. The impact of this change in assumption will result in higher pension projections as members are less likely to breach the limits and therefore incur a tax charge and debit.

The department keeps the rules of the pension scheme under review to ensure it continues to help the NHS attract and retain the staff needed to deliver high quality care for patients. In the past year it has made a number of changes in this area, including reforms to member contributions, new retirement flexibilities for late career staff, and measures to support clinicians impacted by pension tax.

NHS Pension Scheme membership

The department continues to monitor scheme membership rates through ESR. Table 7.5 shows that the overall membership rate for HCHS doctors remains high and has not changed in the last year.

In the last 10 years, however, membership rates for HCHS doctors have fallen by 3%. Further investigation is necessary to explain this, however the department recognises that pension taxation may be a factor. It is also possible that some doctors who opt out may be in receipt of recycled employer contributions. This means that they would not appear in scheme membership data, but would continue to receive the full value of their reward package. Others may feel that they have already saved sufficiently for their retirement. More information about pension tax is provided later in this chapter.

Staff group workforce totals are based on data published by NHS Digital. It is important to note that this data differs from the data on scheme membership provided as part of its evidence to the DDRB in previous years, as the department has made adjustments to the ESR extract used to produce opt-out estimates in order to better reflect the actively working population. The department has also chosen to use data from June rather than July. This is because junior doctor rotations (in July/August each year) mean that lots of staff move around the system in a short period of time, impacting membership rates for a short period.

Table 7.2: NHS Pension Scheme membership for HCHS doctors

Headcount Rate	June 2022 Headcount	June 2022 Membership (Headcount)	1 Year Change	5 Year Change	10 Year Change
Consultant	57,000	91%	0%	-2%	-4%
Associate specialist	2,000	90%	-1%	-3%	-3%
Specialty doctor	9,000	86%	0%	-2%	0%
Staff grade	< 1000	90%	-1%	-5%	0%
Core training	34,000	86%	0%	-6%	-5%
Specialty registrar	18,000	92%	2%	-2%	-1%
Foundation doctor year 1	6,000	93%	-1%	-2%	-1%
Foundation doctor year 2	7,000	92%	0%	-3%	-2%
Hospital practitioner / clinical assistant	2,000	70%	0%	-5%	-10%
Other and local HCHS doctor grades	1,000	82%	1%	-1%	-7%
All HCHS doctors	137,000	90%	0%	-3%	-3%

NHS pensions claimed

The tables below use data from the scheme administrator, the NHS Business Services Authority (NHSBSA) to show the total numbers of GDPs, GPs, hospital dentists and hospital doctors claiming 1995 Scheme pension benefits, as well as the numbers of staff in these groups those claiming their pension benefits earlier than their normal pension age (NPA). This is known as taking voluntary early retirement (VER).

Table 7.3: NHS pension awards for GDPs (1995 section only)

Pension scheme year ending	All pension awards	VER pension awards	% VER of all pension awards
2008	533	193	36.2
2009	423	116	27.4
2010	503	177	35.2
2011	460	124	27.0
2012	464	151	32.5
2013	469	148	31.6
2014	450	139	30.9
2015	532	153	28.8
2016	413	120	29.1
2017	540	151	28.0
2018	475	108	22.7
2019	600	167	27.8
2020	594	156	26.3
2021	560	174	31.1
2022	525	117	22.3

Table 7.4: NHS Pension awards for GPs (1995 section only)

Pension Scheme Year Ending	All Pension Awards	VER Pension Awards	% VER of all Pension Awards
2008	1126	224	19.9
2009	1235	245	19.8
2010	1412	301	21.3
2011	1238	363	29.3
2012	1231	464	37.7
2013	1105	425	38.5
2014	1451	714	49.2
2015	1142	529	46.3
2016	865	397	45.9
2017	1192	614	51.5
2018	1011	450	44.5
2019	1044	473	45.3
2020	1017	433	42.6
2021	943	387	41.0
2022	683	274	40.1

Table 7.5: NHS pension awards for hospital dentists (1995 section only)

Pension Scheme Year Ending	All Pension Awards	VER Pension Awards	% VER of all Pension Awards
2008	61	9	14.8
2009	44	10	22.7
2010	69	12	17.4
2011	53	20	37.7
2012	65	16	24.6
2013	76	24	31.6
2014	55	12	21.8
2015	77	19	24.7
2016	72	27	37.5
2017	50	15	30.0
2018	78	28	35.9
2019	75	20	26.7
2020	72	16	22.2
2021	71	12	16.9
2022	51	15	29.4

Table 7.6: NHS pension awards for hospital doctors (1995 section only)

Pension Scheme Year Ending	All Pension Awards	VER Pension Awards	% VER of all Pension Awards
2008	1400	138	9.9
2009	1499	147	9.8
2010	1687	190	11.3
2011	1898	248	13.1
2012	1828	272	14.9
2013	1559	319	20.5
2014	1858	334	18.0
2015	1776	359	20.2
2016	1854	381	20.6
2017	1954	393	20.1
2018	1886	339	18.0
2019	2144	345	16.1
2020	2285	405	17.7
2021	2292	392	17.1
2022	2352	354	15.1

This data is not directly comparable to data provided in previous evidence submissions to the DDRB, although the department is of the view that it should be more accurate. The data now includes all relevant award types, but members are counted only once. Previously, members may have been counted multiple times, by including revised and cancelled awards, which may have led to an inflation of figures. The new data is also based on the date awards are processed by the NHSBSA, whereas previous awards were calculated using the payable date, which may have led to the numbers changing retrospectively. Data for hospital doctors and dentists is also now provided in separate groups rather than as consultants.

The decision to claim pension benefits is a personal one, and the NHSBSA does not request this when staff make an application. Doctors and dentists may choose to do so for a number of reasons, and it is not possible to isolate the impact of a single factor on retirement rates. It is also important to note when examining the VER data that it does not necessarily mean that staff have left NHS service altogether. Under the current rules of the 1995 Section members are not permitted to rejoin the scheme after claiming their benefits, although many do return to NHS work on a non-pensionable basis. This is known as ‘retire and return’.

As the department has set out in previous sets of evidence to the DDRB, the data shows that GPs are continuing to take early retirement at a higher rate than other clinicians, and further work is required to determine why this is the case. This is also discussed in more detail in the GP chapter.

NHS Pension Scheme contributions

Members and employers are required to pay towards the cost of benefits built up in the NHS Pension Scheme. At present employers contribute 20.6% of each member’s pensionable earnings, plus a charge of 0.08% to fund the administration of the scheme. This is far more generous than most pension schemes offered in the private sector.

Member contributions have historically been tiered based on earnings, with higher earners paying more than lower earners. However, the scheme has moved from final salary linked to a career average revalued earnings (CARE) model, and all members have been accruing CARE benefits from 1 April 2022.

As DHSC’s evidence to the DDRB last year set out, the department therefore considered that reforming the member contribution structure was appropriate, and launched a consultation on a new member contribution structure in October 2021. This was designed to ensure that the costs and benefits of the scheme are more evenly shared, with a view to preserving participation in the scheme and protecting its substantial value for members in retirement. The consultation initially proposed introducing the new structure from 1 April 2022, however, in recognition of wider economic challenges the department decided to delay the introduction of the updated member contribution structure to 1 October 2022.

The new structure narrows the range between the lowest and highest contribution rates and is being rolled out in 2 phases, the first of which was implemented from 1 October 2022. As the new contribution structure is implemented, full-time lower earners are more likely to pay a slightly higher percentage than in previous years, and higher earners are more likely to pay slightly less. This is likely to benefit doctors and dentists, who are generally higher earners in the NHS.

The new member contribution structure also sees contribution rates based on actual pensionable pay rather than notional whole-time equivalent from 1 October 2022. Consequently, many part-time doctors and dentists are now paying less pension contributions than they were last year.

Table 7.7: member contribution structure from 1 October 2022

Tier	Pensionable earnings (rounded down to the nearest pound)	Contribution rate from 1 October 2022
1	£0 to £13,231	5.1%
2	£13,232 to £16,831	5.7%
3	£16,832 to £22,878	6.1%
4	£22,879 to £23,948	6.8%
5	£23,949 to £28,223	7.7%
6	£28,224 to £29,179	8.8%
7	£29,180 to £43,805	9.8%
8	£43,806 to £49,245	10%
9	£49,246 to £56,163	11.6%
10	£56,164 to £72,030	12.5%
11	£72,031 and above	13.5%

New retirement flexibilities

In ‘Our plan for patients’, the department announced its intention to introduce new retirement flexibilities to the 1995 Section, subject to consultation. It launched a consultation on a package of new retirement flexibilities, alongside other pensions measures, on 5 December 2022. The package includes a new partial retirement option for staff to draw on their pension and continue building it while working more flexibly and provisions to allow retired staff to build more pension in the 2015 Scheme if they wish. As part of this package, the department also plans to permanently remove the ’16-hour rule’, which limits the amount of work retired staff can do in the first month of returning to service.

As a result of the McCloud remedy, all eligible staff were moved to the 2015 Scheme for future accrual from 1 April 2022. This means that some members will now have service in both the 1995 Section and 2015 Scheme, which have different rules on how members can claim their benefits. The department has therefore designed the proposed retirement flexibilities to address this issue and ensure that the rules are aligned for all members of the NHS Pension Scheme.

Because the McCloud remedy will mean that some staff may now be able to retire earlier than they had previously planned, the department has also considered that the flexibilities may also support workforce capacity, by providing incentives for staff to remain in service for longer on a more flexible basis.

Furthermore, when the 1995 Section was designed, retirement patterns were understood to be relatively binary; staff would typically work full-time until claiming their benefits and retiring. After this point, members were unlikely to return to NHS service, and the rules of the scheme restricted the incentives to do so by preventing any further pension accrual. However, the department recognises that retirement today is often a gradual process over many years, and staff value the ability to retire flexibly, in a way that suits their work/life balance. The new retirement flexibilities will offer staff increased options at the end of their careers, so that they can partially retire or return to work seamlessly and continue building pension after retirement if they wish.

To ensure that members understand the new flexibilities and can make best use of them, the department has commissioned a programme of communications from NHS England and NHS Employers. This also includes producing materials that will show the value of the new flexibilities to employers and support them to provide the types of employment offers that complement the new options for staff.

The department also believes that the new flexibilities could also support senior doctors and dentists impacted by pension tax to continue to deliver their NHS work whilst reducing their pension tax exposure. This is because if they choose to partially retire and take 100% of their 1995 section benefits, they will be able to crystallise their legacy pension, making future work planning easier.

Pension tax

As discussed in previous evidence submissions, the generosity of the NHS Pension Scheme and well-remunerated careers means that some senior doctors and dentists exceed the annual allowance (AA) and lifetime allowance (LTA) for tax-free saving, and the department is aware that experience of pension tax is important to the retention of doctors and dentists.

The government previously delivered on a manifesto commitment to address the taper issue in doctors’ pensions, by increasing the tapered annual allowance thresholds by £90,000. This is a £2.2 billion commitment which excludes all staff with earnings below £200,000 from the scope of the taper. The most recent data suggests that 86% of contractor GPs and 97% of consultants in England are out of scope. It is important to note that data for GPs includes NHS and private earnings, whereas data for consultants includes NHS earnings only.

The department understands that the increase in GP contractor earnings since the allowances were changed means that more GPs now earn over £200,000 and are therefore within scope of the taper. More information on GP earnings is provided in chapter 5.

For those who do receive charges, the ‘scheme pays’ facility allows members to meet the cost of a tax bill from the value of their pension benefits, without needing to find funds upfront. Where a member uses scheme pays, the member’s tax charge is paid through a deduction to their pension benefits at retirement.

Analysis from GAD demonstrates that for most members scheme pays is a proportionate means of dealing with an AA charge, with the deduction to the member’s pension proportionate to the tax charge incurred. The analysis below shows that it may be a sound financial decision for clinicians to incur an AA charge and use scheme pays to deal with it, as in this case it will have a relatively small impact on the pension accrued. Although scheme pays will reduce the value of the pension accrued, the growth in benefits represents a good return on the contributions made.

The example below considers a 55 year old member with pensionable pay of £150,000. At the start of the tax year, the member has 15 years of service in the 1995 Section and £22,000 pension accrued in the 2015 Scheme following transition in April 2015. Over 2023 to 2024, the member could be expected to accrue pension worth £6,960 per year at retirement. This would be reduced by 10% to £6,250 per year once the scheme pays debit is applied. The graph below illustrates the progression up to retirement of pension benefits accrued and the annual allowance charges incurred over a single year in the post-April 2020 annual allowance regime.

It is important to note that this example is not directly comparable to examples previously provided to the DDRB. Last year’s example member was assumed to be a younger member, with a level of different salary and accrued pension.

Figure 7.4: example growth in pension earned over year 2022 to 2023 for a member with 2015 Scheme benefits and pensionable pay of £150,000

All members who pay into the 2015 NHS Pension Scheme and those members with career average benefits in the 1995 and 2008 Sections of the NHS Pension Scheme (typically GPs and GDPs) have their pension benefits revalued at the end of each scheme year by the 12-month increase in the CPI to the previous September, plus 1.5%. This revaluation helps maintain the purchasing power of career average pension benefits over time.

A higher rate of revaluation benefits members by increasing the size of their career average pension pots, resulting in an increased pension pot at retirement. There is an increased risk of an AA tax charge in a situation where inflation is increasing. However, in situations where inflation is reducing, there may be increased headroom for more pension growth before incurring a tax charge.

To reduce the risk that senior doctors and dentists could face an AA tax charge as a consequence of the current high rate of CPI, the department announced in ‘Our plan for patients’ that it would amend the revaluation date for career average pension benefits in the NHS Pension Scheme for scheme year 2022 to 2023 and future scheme years.

This measure will move the revaluation of career average accrued pension and earnings in a scheme year by 5 days, from 1 April, at the end of a tax year, to 6 April, at the start of the following tax year. The effect would be that the same rate of CPI would then be used for the revaluation and the calculation of pension benefit growth for annual allowance purposes. This ensures that the annual allowance operates as intended in relation to NHS pensions and the high inflation environment does not create higher tax charges. The department set out more detail on this proposal in the consultation launched on 5 December 2022.

The department is also working with NHSE to encourage NHS Trusts to develop appropriate local solutions and has asked NHS England to support NHS Trusts to explore local flexibilities that are available to them within the NHS Pension Scheme. These local solutions include employer contribution recycling, where employers pay the unused portion of employer contribution as additional pay where staff opt-out of the scheme because they have exceeded their allowances for tax-free pension saving.

NHS England are also delivering a retention programme focused on employers making flexible employment offers to staff, engaging their high earners on pension tax issues and promoting the value of the pension scheme. This includes comprehensive communications and piloted seminars to engage staff on flexible retirement options and pension tax.

Communicating the package

So that doctors and dentists can unlock the full value of their reward package, ensuring that they receive clear and accurate communications is important.

Total reward statements (TRS) are provided to NHS staff and give staff a better understanding of the benefits they have or may have access to as an NHS employee. TRS provide personalised information about the value of staff employment packages, including remuneration details and benefits provided locally by their employer.

NHS Pension Scheme members also receive an annual benefit statement (ABS), which shows the current value of their Scheme benefits. On 23 September 2022, the number of statements was 2,812,443, with 297,035 views. This is a small increase compared to the same point the previous year, when the number of statements was 2,716,235 and the number of views 232,008.

The department commissions NHS Employers to provide advice, guidance, and good practice to the NHS on developing a strategic approach to reward, and communications with staff are coordinated by NHSE. NHSE and NHS Employers will provide further information on how individual employing organisations approach reward for their staff in their written evidence submissions.