Fairness on the Frontline

Why Outdated NHS Pay Rules Are Failing Resident Doctors

The principle of equal pay for equal work is a fundamental aspect of fairness in the workplace, and it should be upheld in the NHS just as it is in any other profession. However, a structural issue within NHS pay systems has resulted in a persistent disparity that undermines this principle. This situation is not due to individual decisions but arises from the existence of two conflicting pay frameworks that operate simultaneously, each shaped by different historical contexts and philosophies.

According to an FOI request to the Royal Devon and Exeter University Healthcare NHS Foundation Trust, the role of a Physician Associate is considered comparable to that of a Foundation Year 1 or Foundation Year 2 resident doctor, except for their ability to prescribe medication or order ionising radiation.

Resident doctors are compensated under the Medical and Dental Pay Spine, a legacy system designed during a time when medical careers followed a more linear and predictable trajectory. In contrast, Physician Associates, as the FOI above reveals, are paid at Band 7 under the Agenda for Change framework, which explicitly accounts for demanding work patterns and unsociable hours through structured pay enhancements.

As the NHS increasingly relies on multidisciplinary teams, the coexistence of these two pay structures has led to inequitable outcomes, with resident doctors often receiving significantly lower compensation than their colleagues performing comparable roles under different terms.

A Direct Comparison: The £18,000 Pay Gap

To illustrate this disparity, we can examine an example high-intensity hospital rota, worked by a Foundation Year 1 doctor, and compare it with the earnings of a base of Band 7 physician associate working an identical shift pattern.

A Foundation Year 1 doctor working an average of 46.5 hours per week, including nights and weekends, earns £44,735.60 annually. A physician associate on the same rota, paid under Agenda for Change, would earn £63,033.43, a difference of over £18,000.

This discrepancy arises because Agenda for Change incorporates mechanisms that more accurately reflect the demands of intensive work patterns. It provides time-and-a-half overtime pay for hours exceeding 37.5 per week, alongside percentage-based enhancements for antisocial hours. In contrast, the resident doctor contract offers no overtime premium, a fixed 37% night shift supplement, and a weekend allowance based on frequency rather than actual hours worked.

A similar discrepancy occurs if we do the reverse and place a FY1 resident doctor on an example physician associate rota.

A Physician Associate working an average of 40.5 hours per week, including weekends on rota, earns £51,962.65 annually. A resident doctor on the same rota would earn £38,172.10, a difference of nearly £14,000.

Training and Responsibilities: Key Distinctions

To assess pay fairness, it is necessary to consider the differences in training and professional responsibilities between resident doctors and physician associates.

Resident doctors complete a five-year medical degree, followed by a two-year foundation programme. The General Medical Council regulates them and they assume full legal responsibility for clinical decisions, including prescribing, diagnosing complex cases, and leading patient care.

Physician associates undertake a two-year postgraduate training programme following an initial honours degree in healthcare or biosciences. While they contribute valuably to patient care, their scope of practice is supervised, and they do not hold independent prescribing rights or ultimate legal responsibility for patient outcomes.

These distinctions do not diminish the importance of either role but highlight that resident doctors bear greater clinical accountability, which the NHS should reflect in remuneration.

The Flawed Argument of Future Earnings

A common rebuttal to concerns about resident doctor pay is that their earnings will increase substantially as they progress. However, this argument overlooks the growing barriers to career advancement. Competition for specialist training posts has intensified, with 3.7 applicants per internal medicine training place in 2024, compared to 1.4 in 2019, despite internal medicine generally being considered one of the least competitive specialities.

Many resident doctors now spend prolonged periods in lower-paid jobs without the pay progression and job security available to peers in other NHS roles. Their lives are left on hold, moving from one fixed-term annual contract to the next.

This situation has come about due to the usual UK government fix to everything: take from the rest of the world rather than building here. There has been a massive increase in the number of medical graduates arriving from abroad. Unlike other nations, the UK does not prioritise its graduates for speciality training, a stance that has attracted criticism, including letters to the BMJ. As the GMC workforce report states, “Given that non-UK graduates are increasingly entering postgraduate training and that each year has a new cohort of doctors applying to postgraduate training for the first time, there are questions on whether the UK’s training systems have the capacity to train all the doctors who want to enter”.

The UK government’s response has been to try to put out the fire with a pipette, promising a meagre 333 places per year over three years, funded for one cycle. Yet GMC research reports [Figure 5] that 1047 doctors completing foundation training deferred a year due to ’logistical’ issues (including failure to secure a training post), a figure underlined by the Foundation Programme indicative survey [Table 5] which reports 23.8% of UK FY2 applicants were appointable, but did not receive a training appointment.

The NHS has demonstrably run out of jam for its “jam tomorrow” policy, resulting in resident doctors being treated as little more than glorified temps. Deferring fair compensation on the promise of future rewards has become an unsustainable and indefensible position.

An Urgent Call for a Coherent Pay Framework

This is not a minor anomaly to be addressed in due course; it is an active, ongoing devaluation of the medical profession that demands immediate attention. The solution is not to reduce the pay of other professionals but to demand a fundamental realignment of the resident doctor contract with contemporary workforce realities.

An NHS pay system fit for the 21st century must ensure that clinicians working equivalent hours under equivalent pressures receive equitable remuneration that transparently accounts for their respective training, responsibilities, and legal obligations. To do otherwise is to signal that years of medical training and the ultimate burden of clinical responsibility are of secondary importance to the schedule one works.

Equal pay for equal work does not necessitate identical salaries, but it absolutely requires a rational and defensible approach to valuing contributions. For an NHS facing an existential workforce crisis, and for a government that relies on these professionals to deliver care, ignoring this profound disparity is no longer a viable option. It is a choice: a choice to accept an unfair system that is actively driving doctors away.

Calculations

PA rota and details are based upon FOI request RDF2043 at the Royal Devon and Exeter University Healthcare NHS Foundation Trust

FY1 rota and details based upon an FOI Request to the Royal Free London NHS Foundation Trust

Pay scales are from the government National Pay Scales pages

FY1 Rota

A typical FY1 rota in General Surgery

FY1 Resident Doctor - Medical and Dental Scale

Physician Associate - Agenda for Change Band 7

PA Rota

A typical PA rota. 40-hour week with one 4 hr Saturday and one 4 hr Sunday in a 16-week rota.

Physician Associate - Agenda for Change Band 7

FY1 Resident Doctor - Medical and Dental Scale

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