Introduction
The Society of Radiographers is the professional body and trade union for all those practising in medical imaging and radiography. The Society of Radiographers (SoR) represents over 34,000 members, most of whom work in the NHS across all 4 nations, at all grades across clinical imaging and radiotherapy.
We were the only AfC union to submit evidence to the Pay Review Body (PRB) in 2023. Our arguments for doing so are amplified in 2024-25. These are:
- This is an opportunity to capture the reality of the radiography workforce crisis, putting on record the case for significant additional investment in all areas of radiography, within medical imaging and radiotherapy services.
- Collective bargaining with an elected government of any colour or make up, will never be a balanced process. We believe some independent oversight of pay, reward, workforce development and planning are critical in any NHS pay and reward setting process. An honest and genuinely independent assessment of Government strategy is critical to staff and public confidence in any pay and reward setting process. In the current framework, the PRB are the closest we have to independent oversight; and
- Recent awards have failed to address our key concerns and exacerbated the workforce crisis. This means the service is at breaking point. As such it would be wrong of the SoR to refuse any opportunity to set out our ideas for better choices for staff and patients.
Ultimately, the PRB did not set the recommendation for NHS pay in 2023-24. However, the 2023-24 award has made matters worse. Yet again, members were presented with an award below inflation, which the Bank of England averaged at 8.9% for 2023-24. An overwhelming majority of SoR members rejected the award with a majority voting to take strike action in England. For the first time in our history, SoR members stood alone in taking strike action over pay and their dangerous working conditions. We remain in dispute.
We recognise last year’s negotiations established working groups to look at a range of wider non-pay issues – covering some structural concerns, as well as exploring improving access to flexible working, tackling violence at work, and other areas impacting retention and morale the SoR have repeatedly raised in our PRB evidence. We are a full party to these discussions via the NHS Staff Side. However, these groups have so far produced no recommendations or tangible outputs.
The PRB may think requests to consider and comment upon long-term workforce investment and strategy to be stretching your terms of reference. However, there is no other even semi-independent body in place to assess the Government’s Long Term Workforce Plan (LTWP). NHS Professionals and patients will see it as your responsibility to assess the likely impact of any award on recruitment and retention, now also measured against progress towards the aims of the LTWP.
Furthermore, our evidence highlights pay problems that have built up over time, whilst the PRB process and annual pay cycles have been restricted to and by a short-term spending remit. Any annual pay award creates a pull towards short-term recommendations which is counter-productive, especially against a context of short-term crisis management from the NHS and Government that has become the norm, especially since 2010.
The PRB process is judged by our members and the public on whether it is solving problems or making them worse. If the PRB miss another opportunity to state clearly the need for different and better choices from Government then it makes further industrial disputes more likely, and it will be ever more difficult for even the SoR, and other unions representing Allied Health Professionals, to remain engaged in such a process.
Additionally, the PRB will also be aware of the separate Government consultation about a proposed breakup of the AfC structure, with a proposal to introduce a separate pay spine for nursing. We recognise the place to set out our thoughts on this is in response to that consultation. However, it is impossible to ignore the insight this consultation gives to the wider workforce. We have argued before in our evidence that pay and reward cannot be assessed in isolation from the wider workforce realities, and that the PRB must fully risk assess, and explain, any recommendation against the likely impact on recruitment and retention.
It is against this backdrop that we present our evidence for 2024-25.
Evidence
Recognising and Addressing the Long-Term Workforce Crisis
This year also presents a wider political context. During the 2024-25 pay year there will be a General Election. Like the PRB, the SoR is and will remain politically neutral and non-partisan. However, there is no doubt the state of our NHS will be a more prominent electoral issue than arguably ever before. There is a recognition across the UK that the NHS is in serious crisis. Whatever the makeup of the next Government, they will be needing to reboot the NHS.
Historically, the PRB has accepted funding remits from the Government that have been unsustainable and damaging to workforce recruitment and retention. This year, the PRB has an opportunity to tell this Government and the next what is really necessary and affordable, working with more independence. Further, we believe the PRB has a duty to make recommendations based upon the evidence submitted to it that can guide the discussion on pay, reward and wider workforce investment in a more positive direction.
If the Government seek to yet again restrain the pay remit to within existing spending plans, the PRB must unequivocally challenge this and say it will not be enough. Likewise, it must be clear in saying the Government must foot the full bill for any award.
No potential Government can be allowed to say unchallenged that the UK is spending enough on the NHS. The Institute of Government[i], using OECD figures, have pointed out that the UK spent 84.3% of the OECD average on healthcare between 1970 and 2010, but that this fell between 2011 and 2020 to 62.5%. The Health Foundation cite the UK as spending 18% less than the EU14 average between 2010 and 2019, stating that if we had matched Germany’s spending per head, we would be spending £73bn (or 39%) more each year. To even match the EU14 average would cost £33bn more a year.
During the pandemic there were signs Government understood the need to prioritise finding the money the NHS needed, even if much of this was not spent wisely – for example, the ONS calculating that £47bn was spent on defective PPE and Test and Trace. However, this investment has receded over the last two years and staff emerging from the traumatic pandemic period are losing hope. At the current planned rate of additional spending, it would take 22 years for that £47bn to be re-invested in the post-Covid NHS.
This underspending has been a political choice with consequences for the NHS staff and patients. These are crystal clear when viewed through a radiography lens. For example, from the early 2000s, Germany and France recognised the rising demand for diagnostic imaging. They invested in the equipment and professional workforce to meet this rising demand. As a consequence, Germany has 36 CT scanner and 33 MRI scanners per million people compared to our 9 and 7. France stands at 17 and 18 or more than double our combined numbers. Neither Germany nor France shares our dangerously high numbers waiting extended periods for diagnosis and access to treatment. This lack of investment is also highlighted in the Radiotherapy UK report[ii] showing how cancer patients are waiting too long for treatment due to the lack of investment in therapeutic radiographers.
[i] Staff Side Unions Supporting UK Economic Growth: The case for NHS Pay 2024
Community Diagnostic Centre Programme Failing to Deliver
The SoR welcomed the English Government’s adoption of the Richards’ Report[i] in 2022 which outlined a strategy to address the critical diagnostic supply crisis. Richards’ plan centred on creating around 160 Community Diagnostic Centres (CDCs), where patients could access early diagnosis using new equipment in easily accessible locations. Richards showed how this strategy could more than pay for itself with a range of long-term efficiencies detailed, based upon empirical evidence they worked, such as increasing the NHS Reporting Radiography capacity to save on outsourcing. The strategy recognised patients would need to be supported by 4000 additional radiographers, 2000 additional radiologists and further additional professionals, assistant practitioners and specialist admin support, requiring short-term investment for longer-term benefits and savings.
The Government said it welcomed the report and championed the CDC programme. £2.3bn of capital investment has been sunk into the CDC programme to date. However, there has been no coordinated national plan to find the additional staff for the programme to succeed. The only additional staffing budget seems limited to recruiting 400 radiographers from overseas. So far only 5m of the 17m extra scans needed by 2025 are being delivered. Only around half the CDCs are new or in community settings and a recent APPG report, published in January 2024, describes the CDCs as “Robbing Peter to Pay Paul”. Rather than being the great big idea to turn the tide we all hoped CDCs could be, the reality is that CDCs are currently amplifying, and potentially escalating, the workforce crisis.
Workforce Crisis = Rising Waiting Lists
The National Imaging Board (NIB) is tasked with meeting forecast growth in demand for imaging tests and clearing the pandemic backlog. It isn’t getting close to its 120% of pre-pandemic scans target because it doesn’t have the staff or budget to source and retain them. Its latest report[i], using data from October 2023, saw services running at 112% of pre pandemic levels. At the end of October 2023, there were 1,595,000 patients waiting for a key diagnostic test - a 3% increase since October 2022. 19.9% of patients (218,701) had been waiting more than 6 weeks when the target is 5%. 6.5% of the total waiting list, 71,292 patients, had been waiting for more than 13 weeks. The waiting lists for MRI, CT and Non-Obstetric Ultrasound Scans (NOUS) were still rising. With additional unscheduled scans accounting for around ¼ of all scans being carried out, the target figure would need to be higher than 120% to clear the backlog.
[i] National Imaging Board (NIB) Imaging Transformation slides - December 2023
There are few clearer examples of the NHS workforce crisis, or how it has been fuelled by short-termism overcoming long-term strategic planning, than ultrasound services and the treatment of sonographers.
In October 2023, over 570,000 were waiting for a NOUS, including more than 1 in 5 who’d waited more than 6 weeks. The number of NOUS scans has reached 8.45m, surpassing the pre-pandemic 8.1m by 5% but demand for NOUS scans has increased by 10% in 2022-23 alone.
There is no direct pathway into sonography – it is recognised as an advanced skill. The training pathway has been blocked by failure to release people for training due to increased demand on the existing workforce and some being expected to earn less whilst they train. We estimate 29% of the sonography workforce are near or beyond retirement age, compared to an average age of the radiography workforce being around 40 or younger. Sonography is now one of the largest areas of the independent radiography sector. In 2022-23 agency costs accounted for 8% of all sonography costs.
According to the ONS, average total pay across the whole economy increased between April 2008 and April 2023 by 51%. Most sonographers will work at the top of Band 7. Our research shows that, accounting for the 2023-24 award, this point has increased by only 30% since 2008 – a shortfall in the relative value of a sonographer’s salary equal to £8,054 p/a. (see Table One[i])
Meanwhile, Sonography is an area where we see growing amounts of NHS work being outsourced because the NHS can’t insource demand. The NHS spent £74m in 2021-22 on outsourcing NOUS, at an average of £78.33 per scan when the NHS Tariff was £40. We have no updated figure for 2023-24 but see no evidence this has specifically reduced. We have identified at least 3 regions where the sonography agency rate has reached £120p/h.
We also have rising concerns about the outsourcing of sonography services for NHS patients with limited evidence of adequate due diligence by Trusts in relation to these contractors’ recruitment and workforce practices when using internationally recruited workers.
[i] PRB Research Analysis 2024 (Table 1)
These problems are also reflected in Mammography. Training to specialise as a radiographer in mammography and breast ultrasound are increasingly hard to access, with examples of Band 6 professionals being told they’d need to take a pay cut whilst they train commonplace. The vacancy rate for Mammographers in the breast screening programme has risen to 17.5% in the last year. The vacancy rate for Mammographers on symptomatic programmes is even higher, at 19.5%. Sonographer vacancy rates are up to 14.8%.
Nightingale et al[i] cites Mammographers and Sonographers as the two of the groups most likely to leave in later career due to burnout and injury in the NHS. This is supported by SoR evidence in successful personal injury claims, the vast majority of which involve these two groups of members despite their making up about 1 in 10 of our overall membership.
Most Mammographers will work at the top of Band 6. The top of band 6 has also only increased by 30% since 2008 – presenting a relative pay shortfall for mammographers (and the majority of experienced radiographers in other specialist modalities such as MRI or CT scanning) equal to £6,857 p/a.
A significant above inflation pay award could signpost a recognition of the Sonography and Mammography crisis and encourage more to stay in the NHS. We also want the PRB to specifically acknowledge the NHS professionals pay gap, and recommend Government commit to funding its closure over coming years.
Is Staying in The NHS Bad for Your Health?
The challenges in Sonography and Mammography mirror the wider Radiography recruitment and retention crisis. Whilst the LTWP talks about increasing the number of graduate training places, and signposts towards long-overdue steps to broaden professional entry routes via apprenticeships and wider entry routes, it is missing the chapters on valuing and retaining the existing workforce. It is also missing how it will fund these additional places for future professionals to thrive. These laudable future recruitment plans will fail to even get close to meeting forecast future demand – and thus address rising waiting lists or reduce unnecessary death rates – unless strategic co-ordinated actions are taken now to improve retention and the competitiveness of radiography as a career choice.
NHS vacancy rates for September 2023 reached a record 145,000[i], a 5.4% rise on 2022, with 121,000 waiting in England. According to the latest figures from the National Imaging Board[ii], the mean average vacancy rate for radiography has risen to 13.4%. The vacancy rate is also rising for the imaging support workforce (11.7%) and assistant practitioners (14.8%), both groups being crucial to the potential future professional radiography workforce in the LTWP.
In 2018, the Kings Fund[iii] predicted the radiography workforce needed to grow by 6% p/a in diagnostics and around 7% p/a in therapeutic radiography until 2030 to meet known demand. 2023 is the first year we have reached 6%, growth having continued to average around half of that since 2014.
Our 2023 Workplace Experience Survey[iv] confirmed worrying trends towards ever lower staff morale, impacting on staff retention and patient safety. For the first time, our survey included members working in the independent sector and so also highlighted the perceived differences between the two and so signposts towards why many are leaving.
Our survey highlighted:
An NHS unsafe for patients or staff:
Barriers to career development with:
- About equal numbers of NHS members said they don’t have adequate access to professional development and support than do (48.5% v 46.3%)
- Only 12.5% of NHS members said they had protected study time.
- 46% of NHS members saying their employer did not encourage them to seek promotion.
- 21.5% said promotion wasn’t financially viable for them.
Not enough staff:
[ii] National Imaging Board (NIB) Programme Pack – Dec 2023
[iv] SoR Workplace Experience Survey 2023 (Details available upon request)
The overwhelming number of members responding to our Workplace Conditions Survey who work in the independent sector had previously worked in the NHS. Almost 90% of these returns were from people who had worked for their current employer for more than 5 years. This suggests when they leave, they remain outside the NHS for a significant period of time, although there was also some evidence they may return to use the experience and expertise they left to acquire if the pay and wider conditions support them doing so.
Almost half said they left the NHS to reduce their workload and have greater flexibility over their life. Over 1/3rd said they left for improved career opportunities, pay and reward – reflecting the difficulty accessing training and professional development in the NHS. Over ¼ cited improved professional respect and recognition. Over ¼ cited other reasons that can broadly be grouped into:
- Their NHS department was badly run, with high sickness rates, low staffing levels and burnout.
- They had been the victim of bullying and been under-supported by the NHS.
- They needed greater flexibility when returning from maternity leave/injury than the NHS could offer and so were drawn to better work life balance and access to training; and
- Positive reasons, e.g. the independent sector seems fast paced with more opportunities, more varied work, free parking; or
- Members who had retired said they could still work when the NHS hadn’t offered them that opportunity.
These are clear pointers towards what the NHS could do to better retain, and re-recruit Radiographers attracted into the independent sector.
Professionals Using Their Professional Agency
Our previous PRB evidence has highlighted how NHS practice is fuelling inefficiency by driving professionals towards working for agencies. We have identified numerous members who claim to have had a flexible working request rejected due to staffing shortages only to leave, join an agency and return to their previous department on the hours they had asked for but earning more money in the short term. We recognise this issue has been at least partly acknowledged in the 2023 award, with the creation of a working group to promote positive flexible working, but further examples keep reaching us and pay is outside the Flexible Working Groups terms of reference.
The National Imaging Board’s latest figures[i], from October 2023, highlight that in medical imaging some progress in reducing the agency spend may be emerging - only for a different, equally problematic challenge to emerge alongside it. Spending on AfC agency and locum staff across medical imaging fell in NHS England from £48.1m in 2021-22 to £45.1m in 22-23: a reduction of 6.3%. However, Bank Staff pay costs rose in the same period from 51.9m to 74.1m: an increase of 42.8%.
The SoR believe there are likely to be a number of contributory factors behind this shift. We are aware that some NHS Trusts have sought to shift their Bank staff onto quasi-agency contracts in an effort to reduce the benefits for Bank staff (as highlighted by the numbers who were excluded from receipt of the non-consolidated elements of the 2023-24 award). In parallel, we are aware of more Band 5s and mid-career professionals opting directly to Bank working, rather than continue in department-based roles. This secures some control of their time, increasingly at a premium cost as they remain in the NHS pension scheme but expect hourly rates for all of their work.
The same NIB figures also show where greater efficiencies could be possible if the investment in areas such as Reporting Radiographers was sourced. Medical staff agency and locum costs in the same period rose from 17.6m to 31.8m: an increase of almost 81%. Medical staff internal bank pay costs also rose from £18.4m to £25m: an increase of 36.1%. Overall, agency and bank costs for imaging services rose in 2022-23 from £135.9m to £176m: an increase of 29.4%.
[i] National Imaging Board (NIB) Programme Pack – Dec 2023
Pay Restoration Needed to Address Uncompetitive Salaries
The relative pay shortfall highlighted above for Sonographers those on the top of Band 7 and those at the top of Band 6 is far from unique.
Analysis of AfC pay movement between 2008 and 2023 (see Table One[i] below) shows the impact of long-term under-funding, mixed with short-term problem solving. This has created a toxic mix that is forcing many to leave the NHS.
The SoR do not believe that demolishing the AfC structure is safe or sensible. However, continuing to ignore the evident strain on specific parts of the structure will inevitably lead to its collapse. The consultation around a single pay spine for nursing grades should, whilst being rejected as the wrong solution, be grasped by the PRB as an opportunity to highlight the inherent risks and strains evident in the current structure.
The RCN’s grievances, prompting their call to secede from AfC, are sourced by problems recognised and shared by our members, namely:
- Under-investment in pay as a whole but especially Band 5.
- Failure to recognise and remove barriers to progression, and unintended side effects that hinder recruitment and retention (such as pension penalties in Band 5 or the cumulative impact of not paying overtime at 8a).
- Failure to support job evaluation, revision of job descriptions and extend job profiles to reflect how professional roles have developed since AfC was introduced - including a failure to utilise Annex 20 more widely; and
- Under-investment in staffing numbers – the side effects of which include failing to support safe working and professional progression generally.
[i] PRB Research Analysis 2024 (Table 1)
Table one[i] shows the extent of under-funding across the AfC pay bands relative to the rest of the economy since 2008. Whilst it is true that wage growth and prosperity has shrunk across most areas of the economy since the banking crash, the prolonged extension of austerity measures on the public sector have limited growth in spending on the NHS (as highlighted above) and left almost all NHS staff relatively worse off than workers in other sectors. The 2023-24 NHS award exacerbated this by leaving the NHS further behind other parts of the public sector as well.
Only those at Band 1 and 2, who have barely kept up with increases to the national minimum wage, and the starting point of Band 3 have kept up with rises across the economy as a whole. A pay gap has emerged.
This table shows that pay band maxima, critical for retention and sustaining a professional workforce have fallen dangerously behind the rest of the economy from Band 4 upwards. They show unequivocally that there has been a process of devaluing NHS leadership roles with Band 8 and above being given half-inflation pay awards as an average since 2008. They also show the pinch points that disproportionately impact key points critical to recruitment and retention to achieve the aims of the LTWP. The structure now looks like it is designed to make people want to leave.
This is illustrated by looking at key groups of radiography professionals.
[i] PRB Research Analysis 2024 (Table 1)
Whilst the pay gap is less pronounced for starting salaries below Band 8, the critical exception is the professional entry point for new arrivals and graduates at Band 5. Here the pay gap was 11% from April 2023, as opposed to 1% at the entry point for Band 7 for example. The Band 5 starting salary pay gap is £2,225. This has happened in plain sight, but no-one seems willing to claim ownership of the plan. Regardless of whose fault this is, something has to be done to address it urgently if the NHS is serious about its LTWP recruitment targets. 2023 was the first year that therapeutic undergraduate courses continued to have unfilled places.
Band 5 starting salaries are increasingly uncompetitive, with at or above £30,000 now a common benchmark for graduate entry roles even in other parts of the public sector like teaching, social work or probation. Retail management traineeships would pay higher still.
Since 2022, we have modelled the reality for a third-year graduate Band 5, trying to survive on their basic salary, living in a shared rented 2 bed property in Salford and included this in our PRB evidence. Our research shows that after each of the last three pay awards our Salford Rad’s real disposable income has fallen in actual terms. After the 2023-24 award, this Salford Rad’s real disposable income (after basics like rent, transport, utilities, etc) has fallen to only £123 p/w – a reduction of £25 p/w on 2022-23 and £55 p/w since 2021-22. From this they will need to buy food, clothes, any further study materials and sustain any kind of social life. If they needed to run a car, it is possible they would already be starting each month with wages not covering outgoings. (See table two[i] for breakdown).
We have also previously raised additional pension barriers designed into the Band 5 pay that neutralise pay progression. A Band 5’s first increment is now worth £2,232 p/a. However, if they’ve remained in the NHS Pension Scheme, their contributions increase from 7.7% to 9.8%, swallowing up £816 or 37% of their increase. It is little wonder that Band 5 are the group most likely to opt-out of pension membership, further harming the NHS scheme. We urge the PRB to specifically recommend these be addressed without further harm to recruitment and retention.
Evidence from Nightingale et al[ii] looking at radiography retention further supports what we’ve said to the PRB since 2022 and repeat now. New Professionals have an insidious choice of either:
- working excessive amounts of overtime to feel they are progressing financially, at which point they become time poor and start to burn out, or
- looking to leave, for more lucrative locum/agency roles that hinder their professional development or leaving radiography altogether.
The need to feel valued and professionally supported is identified by Nightingale et al, as being especially important for New Professionals, in particular in Therapeutic Radiography who conversely suffer most from having limited support and career development.
The SoR supports exploring ways to counter this long-term devaluation of NHS professional roles, such as writing off student loans and offering pension holidays for those who remain in the NHS for agreed periods. These could be important signposts of a change in culture, if supported by sustained investment to secure wide pay restoration.
However, the SoR believe the PRB must specifically highlight the pay gap at the entry point for Band 5, recommending higher starting pay.
In parallel, we also encourage the PRB to support protections on working time for new professionals entering the NHS, with recommendations to limit excessive hours, guaranteed CPD time and supportive preceptorship programmes that facilitate accelerated progression into Band 6. This can be supported by mechanisms already in place within AfC Annex 20. Doing so is critical for recruitment and retention.
[i] PRB Research Analysis 2024 (Table 2)
Assistant and Support Staff
One of the greatest risks of separating the nursing profession from the rest of AfC would be losing the connection between the ever-important Assistant and Support workforce who are in bands 3 and mostly band 4 from the bands that require graduate entry, and the professionals they work most closely with.
Assistant practitioners and Imaging Support workers have been identified in the LTWP as critical groups to retain and grow. There is enormous potential to grow from within, by expanding and advancing Assistant practitioners and Support grade staff, as recognised by the Richards Report[i]. They have also been identified as groups from which we could widen the source of potential Radiography professionals as we strive to meet the huge increase in demand across diagnostics, radiotherapy and other areas of medical imaging.
However, we are not doing enough to recruit and retain this critical strategic group. The latest National Imaging Board Figures[ii] show the vacancy rate for Assistant Practitioners excluding screening is 14.8%. For Assistant Practitioners working in Mammography screening, the figure has risen to 16.3% in 2022-23. The Imaging Support Workforce vacancy rate has risen to 11.7%.
Table one[iii] shows this group are also being failed and devalued year-on-year. As a percentage, Band 4 starting pay has risen by less than Bands 3, 6 and 7 since 2008. The relative pay gap at the start of Band 4 from last April is £1,039 p/a. However, loyalty is poorly rewarded. The maxima of Band 4, a ceiling below the professional grades re-enforced by the need for graduate level qualifications, has increased by even less than the maxima of Band 3. The percentage pay gap to the rest of the economy at the top of Band 4 is 19%, equal to £4,963.
The 2023-24 award re-enforced this long-term devaluation. Despite the highest inflation level in living memory, another below-inflation award saw someone at the top of Band 4’s pay increase by only £26p/w gross or £15 p/w net.
The SoR recommends that the PRB openly acknowledge this devaluation in the support workforce.
We also call on the PRB to cite the pay gaps in Band 4 and how this contradicts the aims of the LTWP as evidence recommending Government’s commitment to funding pay restoration in addition to future inflation proof awards for all bands.
[ii] National Imaging Board (NIB) Programme Pack – Dec 2023
[iii] PRB Research Analysis 2024 (Table 1)
AfC pay awards have understandably prioritised securing at least the minimum wage for the lowest paid. Doing so from a pay cake repeatedly too small to feed the whole has however been embedding into AfC structural disincentives to taking on leadership and management roles.
In our 2022 evidence, we used ESR data and our own research to highlight the number of radiographers in roles at Band 8b and above has flatlined since 2014, despite the relative growth in the total radiography profession in the same period. We have seen no evidence of improvement since. Analysis of the pay gap goes a long way to explaining why.
Starting salaries from 8a upwards have been consciously reduced year-on-year by more than other bands (see Table one[i]). The same has happened to band maxima from Band 8a and above. Their roles have been actively devalued. To make matters worse, the progression rungs have been removed and they now have to wait at least 5 years for any pay progression.
The jump from the top of Band 7 to the start of Band 8a is now only 1.8%, or £17 p/w gross or £11 p/w net. With overtime being unpaid at Band 8a and above, almost all new Band 8a are likely to face a cut in take home pay for at least 5 years if they stay in the NHS on promotion. Only in the NHS would someone be expected to earn less on promotion as a reward for additional responsibility.
The gap from the top of Band 7 to the top of 8a has also been devalued to only 12.8% gross or 10.7% net, as opposed to the gap between the top of Band 5 and top of Band 6 which are now 18.9% (gross) or 16.1% net.
If early diagnosis and access to early treatment in cancer are the key measures of the UK’s health strategy, then medical imaging and radiography are the keystones. It follows that having senior leaders who understand radiography would be positive; for example, it could prompt local Trusts to prioritise how to make efficiencies from developing more Advanced or Reporting radiographers. However, not only are their roles being actively devalued, but their experience is also that they are finding the jobs getting ever more difficult.
In 2022, we launched a Manager Members’ Survey[ii] which illustrates why. It found:
- Only 54% said they’d been in their post for 3 years or more, suggesting high turnover.
- 52% said they manage 20 or more staff.
- 39% said they manage 30 or more staff.
- 45% said they had received no specific training from their organisation in managing their team.
Many managers also tell us they retain some direct clinical responsibility or often step in as cover, due to staffing supply problems. Our own pay research[iii] shows leadership grades in the grip of a long-hours culture. There is no significant difference between the number of extra additional hours worked regularly by members in different pay Bands until 8b and above, averaging between 4 and 6 for Bands 5 to 8a, before rising to an average 11 additional hours a week for 8d. All bands had members working significantly longer than this at least occasionally, with the Working Time Regulation limits regularly passed in all Bands.
The SoR believe the PRB must openly acknowledge this devaluation of NHS managers and leaders and recommend:
- An immediate additional increase for the minima of each Band from 8a upwards.
- All Band 8s should have access to paid overtime – reducing the risk that promotion will not pay whilst introducing a disincentive to sustaining excessive working hours.
- An NHS-wide review of the use of Working Time Directive opt-outs, to reduce the risk of burn out, including amongst managers and leaders.
- Specifically acknowledge the NHS professionals pay gap and recommend Government commit to funding its closure over coming years; and
- Support a review of how progress through the pay range can be accelerated for Band 8a and above.
[i] PRB Research Analysis 2024 (Table 1)
[ii] SoR Members Pay Survey 2022 (Details available upon request)
[iii] PRB Research Analysis 2024 (Table 1)
Conclusion
9 out 10 NHS patients are now supported by a Radiographer at some point in their treatment pathway. The evidence above sets out the challenges facing the NHS through the medical imaging and radiography lens, the keystone in bridging the nation’s challenges around health inequality, access and outcomes.
If the NHS continues to fail Radiographers, the nation’s health, and the NHS, continue to fail. The cost of the staffing crisis isn’t just financial. Our evidence shows how the staffing crisis impacts patients by causing longer waiting times for scans and therefore delays in treatment. This in turn lowers national morale and confidence in our NHS which damages the country’s collective health, confidence and eventually the economy. However, the solution has to start with a commitment to spending more and spending better.
Failure is far from inevitable. Other countries with better health outcomes and shorter waiting times like France and Germany show what investment and better political choices delivers for patients. As the Richards’ Report[i] identified, there are huge opportunities for radiography and medical imaging to be at the centre of innovative, efficient solutions to early diagnosis and reduced waiting times for treatment. However, as we are seeing with the unravelling of the CDC programme, goodwill alone will not deliver results and staff cannot continue to be an afterthought.
Critically, our evidence highlights how the crisis is founded upon poor short-term political choices – chiefly to under-fund the NHS and social care. Laid on top of the foundations is the complicity of NHS leaders in compromising around these poor choices, then failing to develop and sustain a credible strategic workforce plan. These weak foundations now threaten to bring down the AfC structure.
Each year the annual pay round, with the PRB centre stage, engaging but ultimately performing to the Government’s script, has tried to distract staff and patients from the consequences of the failures. Last year the audience heckled. Some left. Now the PRB risks being trapped and buried by AfC’s collapse unless it instead uses the opportunity to sing a new and different tune.
2024-25 presents a new backdrop and a broader script with room and space to improvise as an imminent General Election and evidence the electorate are prioritising better outcomes for the NHS gives all stakeholders, including the PRB, an opportunity to act more independently.
Recommendations
The SoR urges the PRB to find this independent voice and recommend:
- A significant, above-inflation pay award for 2024-25 for all AfC grade staff at all grades.
- This should be paid as close to 1st April as is possible. However, we are conscious the General Election and ongoing consultation around removing nursing from AfC could delay a Government decision. This should not delay the PRB from making a recommendation and doing so publicly.
- They should also recommend this is fully funded by Government, unlike the 2023-24 award where Government met only 3.5% of the award, most of which they recovered through additional tax and pension contributions, aided by how and when it was implemented.
Recognising that one above-inflation pay award will not undo 15 years of under-funding and devaluing NHS professionals, the PRB should also recommend:
- Government commit to full pay restoration by fully funding above-inflation awards at least until NHS pay is restored to 2008 relative levels, for the top of all pay Bands.
- This is underpinned by a minimum inflation +1 underpin on all future NHS pay awards, preventing the pay gap from re-emerging.This mechanism would mirror that guarantee afforded the NHS pension scheme. Never again should the only way to secure an inflation-proof pay award be to leave the NHS to protect the value of your pension.
Furthermore, the PRB should support the following specific, targeted measures to improve recruitment and retention and ease the strain on pinch points in the AfC structure:
- Support feasibility studies into writing off student loans and exploring paid pension holidays for new professionals and professionals working in harder to reach NHS areas, as part of broader recruitment and retention incentives.
- Significantly increase the starting salary for Band 5 new professionals to make an NHS professional career more competitive and sustainable.
- Recommend removal of the New Professional Pension Penalty which undermines pension scheme membership.
- Support extending preceptorships and the use of Annex 20 to facilitate faster progression to Band 6 for NHS New Professionals.
- Significant increase to the starting pay at Band 8a, alongside faster progression to an improved maxima for all managers and leaders in Bands 8 and 9.
- Support the introduction of paid overtime for all Band 8 and 9s, in part to remove the disincentive to promotion and in part to actively disincentivise a long-hours culture amongst managers and leaders called upon to manage services safely and budgets efficiently.
- Recognise the need to protect all NHS professionals from excessive hours by supporting a full review of working practices, an over-reliance on overtime amongst professional grades and a positive conclusion to ongoing Working Groups on minimising violence at work and promoting greater flexibility and work-life balance.
Additionally, the PRB should indicate clear support for:
Funding to secure all job profiles are reviewed and adequate training and support provided to all Trusts so that job evaluation can work safely and fairly for all.
Additional support for fully independent auditing of the impact on this and future pay awards on long-term recruit and retention, including measuring and publishing progress against future demand identified in a revised LTWP. If the PRB thinks fulfilling this wider remit would be outside of credible terms of reference, then it should consider and comment upon whether their process would benefit from an additional independent body conducting this function to inform future pay and reward processes.
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