Why does the NHS pay women less?

Mark Dayan and Fiona Johnson look at the gender pay gap in the NHS, what might account for it, and its implications for the health service.

Blog post

Published: 16/02/2018

The BBC today reported findings from a data request into what NHS consultants are paid, and how this differs between men and women. The headline findings show a striking discrepancy. 95 out of the 100 highest paid consultants in England are male, and on average female consultants earn nearly £14,000 a year less than their male counterparts.

The dividing line

Looking at the underlying figures from NHS Digital, we can see some interesting patterns. The graph below shows how we would expect pay for men and women to line up if they were equally paid – and then how different five-year age groups, shown as blue dots, diverge from this. The average for all age groups is shown with a black dot. Men earn more in every age group, except the tiny number of consultants still practising over the age of 70. The gap peaks between the ages of 40 and 54.

Breaking down the type of pay shows even bigger differences. Male consultants only receive slightly more in basic pay than their female counterparts: the gap really opens up when we also consider “additional pay”. The data doesn’t break this down, but we know that the main components for consultants overall are pay for overtime and additional work, such as waiting list initiatives and time spent on call, and clinical excellence or other awards for good work.

What’s going on here?

So what accounts for this gap? Is it simple discrimination? Is it a reflection of wider social norms that differ between men and women? Or do male doctors somehow earn their higher pay? The Nuffield Trust plans to undertake research that we hope will go some way to answering these questions. We hope to analyse the entire NHS workforce and draw on well-established methods to assess what accounts for differences between male and female pay. We should be able to look at the gap by age and profession for everybody – and split out how much is caused by the different characteristics of male and female workers, and how much is not.

But in the meantime, research on pay and gender in the UK more widely already gives us several pointers to look at. For a start, it is clear that part of the headline gender pay gap simply reflects men being more likely to work full time.

But this is not the whole explanation – and in fact the data the BBC uses is only counting full-time workers. Women also earn less per hour in work, and their hourly wages flatten off as they age, while those of men continue to rise. This difference is most pronounced for women through their thirties and forties, and researchers at the IFS cautiously conclude that “the arrival of children may have something to do with it”. Because women in British society are more likely than men to give up their job or go part time while their children grow up, they miss out on opportunities to rise through the ranks.

A consultant quoted in the BBC article notes that, although she is “surprised and disappointed” by the figures, she thinks “men are more likely to do overtime”. Assuming that this is the case based on the differences in additional pay, that too might well reflect the impact of caring responsibilities. Chief Medical Officer Dame Sally Davies suggests in the article that women “falling behind” when they have children may make them less likely to reach a level where it is easy to claim overtime.

Is this fair or efficient? On the one hand, it is not simply direct discrimination. On the other hand, you might ask whether a system where continuous time served is valued enough to create such a wide differential, and where higher-paid overtime plays such a prominent role, is itself inefficient, and perhaps institutionally sexist.

There is also a small pay gap even at younger ages. This could reflect discrimination – for example, if there is a difference in awards for excellence between men and women, might it partly be because women are less socially encouraged to push for them or get refused more when they do?

It could also reflect men being in relatively higher paid occupations – which the ONS found had a significant explanatory role. Again you can see this in two ways: at an individual level with women choosing jobs that pay less well, or a structural level where equivalent jobs with more women in them are paid less, as was found in a spate of lawsuits against councils in the previous decade.

What does it mean for the NHS?

Two characteristics make these questions especially important for the NHS. First, more than three-quarters of its workforce is female. There are more female nurses alone employed by the English NHS than there are male staff in every category combined. And second, the NHS is seriously struggling to recruit and retain enough workers to deliver services.

So if women working for the NHS are missing opportunities to progress and improve their skills because of the way that career breaks or part-time working are treated, or, for example, because shift patterns are difficult to reconcile with family life, then this is a major problem for the service as a whole. And if predominantly female professions tend to be undervalued, then this might do something to explain morale and retention problems – and even the remarkable lack of a coherent plan for dealing with these.

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