Industrial action in the NHS has renewed interest in how much doctors earn. In a debate short of independent analysis, we have revisited the data to outline some fresh perspectives on medics’ earnings. In particular, we focus on common questions about doctors’ pay in England – namely how it has varied over time, how it compares to the wider labour market, and how it stacks up against pay in other countries.
Commenting on pay is tricky, as it is an inherently sensitive and complicated topic. There are many ways to present earnings and put them in perspective, and all have their own limitations and are sensitive to the choice of assumptions. These words of caution extend to the measures presented here. The intention of this explainer is to help colour in part of the complex picture and not seek to provide an exhaustive overview. We are not intending to determine what a fair level of pay would be, but rather inject objective evidence into a problematic dispute.
What was the pay deal for doctors?
The pay deal announced in July – which covers the year to March 2024 – means consultants’ pay will increase by 6%, with doctors in training getting a £1,250 uplift in addition to this (equating to an average 8.8% increase in total).
As a result, consultants’ basic NHS pay will be between £93,666 and £126,281, with average full-time NHS earnings likely to be around £143,100 once additional earnings are included to cover things such as on-call responsibility, medical awards, geographical allowances and additional activity.
For junior doctors, basic pay will be between £32,397 and £63,162, with average total full-time earnings likely to be around £41,300 for those in their first year of practice, and £71,300 for specialty registrars towards the end of their training (Table 1).
How have doctors’ salaries varied over time?
We have previously charted how average salaries changed for doctors in training, consultants and other NHS groups. We estimated that consultant and junior doctor salaries would be around 14-15% lower in the year to March 2023 compared to what they were 12 years earlier, after accounting for inflation. We noted that these estimates depended on levels of inflation (and pay) over the rest of that financial year, but in reality these estimates proved very close to the actual trend.
However, by using different information on actual pay settlements, we are able to look further back and also control for changes in the seniority and experience within grades which may affect that previous analysis. This too came with challenges – the information about what was implemented is somewhat patchy and some pay deals were staggered over the year.
That said, the trend reveals a striking picture of sustained periods of real-terms increases followed by similarly sustained periods of real-terms decreases in pay. These ebbs and flows are problematic as doctors – like most of us – are typically loss averse, feeling the downside of real-terms cuts more acutely than the upside of real-terms increases. In fact, while the minimum basic starting salary of consultants in 2022/23 (around £88,000) was lower after adjusting for inflation than it was one decade ago (£96,000 for 2012/13 in 2022/23 prices), it is the same as two decades prior (also £88,000 for 2002/03) and higher than three decades earlier (£75,000 for 1992/93). These chart data relate to the underlying pay frameworks and not the actual pay packets of individuals, which will increase due to movement to more senior training posts, and to reflect consultants’ years of service (as shown in Figure 4).
The trend reveals the importance of the choice of baseline when looking at changes over time – the pay scales of junior doctors and consultants have fallen in real terms over the last decade or so, but over a longer timeframe they have actually fared well compared to inflation. The chart also shows the challenge when the employment landscape shifts. Doctors in training and consultants have typically had similar pay settlements, but the four-year deal for junior doctors – equivalent to 2% annually – was agreed prior to both the challenges of working through the pandemic and spiralling inflation which quickly made it look like a poor deal.
While this analytical approach has advantages, it is limited to the pay settlements and does not capture the effect of other contractual changes. Notably, in the year to 2003/04 – which covered the introduction of their new contract – total earnings per full-time equivalent consultant were reported to increase by 12% in real terms (with basic salaries having increased by around a quarter). A survey conducted at the time suggested that consultants who switched to the new contract received an annual pay increase that year of £12,454. This was admittedly two decades ago, but it is informative as it characterises a problematic scenario whereby government increases pay above what it perceives as affordable and then – painfully – will follow it with periods of sub-inflationary deals to claw back costs. More recently, changes to pension tax will particularly benefit consultants financially but, as with other wider changes, are not picked up in the analysis of pay uplifts.
There have also been various changes to junior doctors’ NHS employment terms and conditions, which also need to be factored in when comparing pay over time. For example, the gradual introduction of the European Working Time Directive reduced their maximum weekly work hours from 56 to 48 in the five years to 2009, which impacted the hourly equivalent wage over this period. While their 2016 contract was designed to keep average earnings the same, the balance of earnings between basic and additional pay and rates changed. More recently, the broader terms of 2019’s multi-year pay settlement included adding an additional pay increment level (meaning, for example, that the total investment for 2020/21 was in reality 3%, as opposed to the headline 2%). That is not reflected in the chart above, which we have restricted to just the pay uplifts.
How do doctors’ salaries compare to earnings in the wider economy?
It is also informative to consider how doctor pay compares to salaries across the wider economy in England. The latter data are only available up to 2021/22, and the comparison is not straightforward. However, at that point the average NHS earnings of doctors in their first year of work was above the median, so more than the majority of workers but below the mean wage. Specialty registrars’ average NHS earnings were higher than the salaries of nearly nine in 10 of the wider workforce, while consultants’ earnings sat between the 98th and 99th percentiles. For consultants, this relative pay level has been consistent over the last decade, but for junior doctors they have slipped down the percentiles over time.
GP partner earnings – which are drawn from their practice’s profits rather than directly determined by a national pay framework – are higher still relative to wider labour market earnings. However, it is worth mentioning that GP partner earnings increased by 17% in the last year covered in the data, which is likely to relate at least in part to additional payments made during the pandemic. Some of that funding may not be extended. In addition, their figures are fairly sensitive to the assumption required to convert GP earnings per head (£142,000 for a partner) to earnings per full-time GP. Specifically, GP partners were at the time, on average, contracted to work 87% of a full-time contract. It is not necessarily the case that increasing their contracted hours would have a commensurate impact on their take-home pay.
These analyses are limited to NHS earnings of doctors, who may also work outside the health service. The data on wider earnings are disappointingly limited. In fact, a previous survey (albeit now dated) found that only one in eight NHS employers actually had accurate information on how much private practice work all their consultants were doing. However, even older research had found that private practice accounted for, on average, nearly a third of consultants’ total earnings but varied hugely by, for example, speciality, and this level may well have since changed. The data available on wider labour market earnings are limited to employees, however, and do not include profits earned by business owners, for example, which could account for a fair number of the high earners. The chart also does not account for the financial value of pensions, with the NHS schemes particularly generous.
Getting into medical school is competitive, will often require students to take on considerable student debt, and the training and work is challenging, so we may well expect doctors to be among the very highest earners. Ideally, it would be possible to compare to a subset of professions more similar in nature to each of these medical grades, but the available data is not sufficient to do so. That said, previous work has looked at the effect of a medical degree on lifetime earnings and it appears favourable, even controlling for other factors including prior attainment.
How do consultants’ salaries compare internationally?
Particularly in light of the string of media reports on clinicians seeking to move abroad, it is also useful to consider how doctors’ salaries compare to other countries. In fact, the BBC particularly asked for us to look at this measure. There are again limitations, with no readily available information on junior doctors as well as variation in wider employment terms and conditions, including pensions and working hours. The available earnings data for so-called ‘specialists’ (which covers consultants) are patchy, with some countries like England only having information for salaried doctors. For other potentially useful comparison (such as with the USA and Australia), it is only available for self-employed doctors, who are typically paid more.
There are different ways to compare earnings between countries, including by adjusting for exchange rates or in relation to the costs of goods (purchasing power) or average earnings in that country. But – notwithstanding the general point that international comparisons need to be treated with a degree of caution – whichever the choice of measure, England appears to rank below some countries, such as Germany, but above others, such as France, in terms of salaries of specialists.
It is also useful to consider the differences in pay across the UK. Although there are no readily available data on hospital doctors’ overall earnings (including non-basic pay) other than in England, we can compare between basic salaries. For junior doctors in Scotland, Wales and Northern Ireland (which share similar contract terms for these medics), pay increases incrementally after each year of training, whereas in England (where the junior doctor contract diverged from the other UK nations in 2016) there are larger but less frequent pay rises. For instance, those entering their sixth year of specialty training in England are paid £63,152 a year, whereas their equivalents in Northern Ireland are paid £50,903 (but with the potential to increase up to £60,260, depending on the length of the training programme).
For consultants, there are differences in the relative size of pay increases based on years of service. After four years of working as a consultant in England, Scotland and Northern Ireland, basic pay increases by 2.9%, while those in Wales receive 5.7% more. That said, basic pay appears to flatten earlier in Wales for the most experienced consultants compared to their counterparts in the other three nations. Again, this comparison needs to be interpreted with caution. In England, non-basic pay accounts for around a quarter of these doctors’ earnings, so differences in how these additional earnings are allocated and awarded could have a substantive influence on the variation in actual take-home pay.
Overcoming the impasse
While pay is inevitably central to the discussions around the current industrial dispute and also a very tangible way to value doctors’ contributions, policy-makers need to be more creative and proactive on wider factors affecting staff retention and wellbeing. Better work-life balance, delivering high-quality care and appropriate autonomy are all, for example, known to be important. The pressure of the pandemic and efforts to clear the elective backlog have left staff feeling undervalued and exhausted, which only emphasises the importance of looking at improving these wider working conditions.
No one measure is sufficient to determine what pay deal should be offered or considered fair. But a shortage of independent analysis has meant that much of the debate has been based on flawed figures. All too often true levels of inflation have been misrepresented, basic pay conflated with total pay, starting pay presented as average pay, whereas affordability arguments often do not recognise that some additional pay is returned to the public purse in taxes. Given the potential impact of strikes on doctors and their colleagues, as well as on patients and the public, the topic warrants a better-informed discussion. That, alongside overdue reforms to the official pay review process, could help overcome the apparent current impasse.
Methodology
Scope
Given the recent strikes have been conducted by doctors in training and consultants, we have primarily focused on these two medical staff groups in this explainer. That is not to say that the pay of SAS doctors, for instance, is not important.
A note on inflation
We have used consumer price index (CPI) in this analysis. A similar measure, which includes owner occupiers’ housing costs and council tax (CPIH) would give similar results as the two indices have tracked closely in recent years. Some other analyses have used retail price index (RPI) as the measure of inflation, although it does not meet the required standards for designation as a national statistic and is widely considered to overstate inflation.
To estimate inflation over 2023/24, we have used the actual CPI levels for the first three months of the year and then the OBR’s quarterly estimates for the remainder. This equates to an estimate of 5.9%, although it is important to note there is a large degree of uncertainty around this. The pay review body noted, at the time of receiving their evidence, the OBR had expected inflation to average 5.5% over 2023/24.
Table 1. Overview of recent doctor pay settlements, basic salary and average earnings
For hospital staff, full-time NHS earnings are based on the sum of mean basic earnings for full-time equivalent and mean non-basic pay per person. For GPs, the average earnings data, published per person, are uplifted by average contracted participation (part-time working) to generate a full-time estimate.
This has been calculated by applying the pay settlement to the earnings from 1 April 2022 to 31 March 2023. For consultants, the medical awards earnings have not been inflated from last year. Estimated earnings for 2023/24 are rounded to the nearest £100.
Numbers employed include those in both general practice and NHS hospital and community services, as at 30 April 2023. Headcount data exclude foundation year doctors working in general practice (as published data was not sufficient disaggregated) and would exclude GP registrars from any practices that did not submit data.
The pay settlement and estimated earnings for 2023/24 for SAS doctors is based on the 6% uplift for this staff group on pre-2021 contracts. Salary scales for specialty doctors on the 2021 contract and the specialist grade have been increased by 3% with further detail provided in the latest pay circular.
‘Other and locally employed doctors’ covers the ‘Hospital Practitioner / Clinical Assistant’ and ‘Other and Local HCHS Doctor Grades’ categories recorded in the NHS Digital datasets.
GP partner uplifts (2022/23 and 2023/24) based on headline changes to funding levels to practices and may not reflect how actual salaries change.
Figure 1. Real-terms pay settlements for consultants and junior doctors since 1990
Real-terms uplift is calculated by adjusting for inflation (CPI) over given financial year from the pay uplifts as outlined/published by the Department over that corresponding year (from 1st April). There are a few exceptions. In 2006, the pay uplift was staggered with a first uplift in April followed by a second in November. In these instances, we have taken the total uplift for the year (for example, 2.2% in 2006 where 1% was given in April followed by 1.2% in November).
For almost all years, the pay award is set out as a percentage (relative) pay uplift. However, in some years (2007 and 2023) an absolute uplift (i.e. the same amount for all pay points) is used. As this results in a different percentage uplift depending on where you sit on the pay points, an average percentage uplift has been taken. These percentage uplifts are cross-checked with figures published in Appendix G of the 2022 Review Body on Doctors’ and Dentists Renumeration.
In some years, the total investment or changes in total pay may differ from the pay uplift because of specific changes to the other sources of income (such as local or national Clinical Excellence Awards), or introducing a new spine point for junior doctors such as in 2019. Some of these have been annotated on the chart.
A new contract for consultants was introduced in 2003 so from this point forward on the chart, pay uplifts are those for the new (2003) contract as most consultants will have moved onto it. For most years there is no difference between pay uplifts in the two contracts, although in the initial years following the adoption of the new contract, 2003 uplifts were higher than pre-2003. Similarly, junior doctor uplifts post 2016 are those as specified for the 2016 new junior doctor contract.
Figure 2. Estimated average NHS earnings of doctor compared to the earnings distribution across all jobs in England, 2021/22
All estimates are for full-time staff. For median, mean and 75th to 90th percentiles, hourly earnings are used and weighted to a 40-hour contract. Hourly data are not available for 95th percentiles and above so these are based on annual salaries, which represent a slight underestimate given these particular data count full-time as 30 hours and above. The salary level is the average for that grade and not the starting salary.
Doctors will often take considerably longer to reach more senior grades than the typical minimum given and also among the longest pre-registration training (typically five years as an undergraduate). The ’specialty registrar’ group will include some in run-through training who will typically start a minimum of two rather than four years into employment.
Calculation of earnings is described in methods for the first table (above). Wider labour market salaries are based on the Annual Survey for Hours and Earnings (ASHE), which includes employer responses for a 1% sample of employee jobs, using HM Revenue and Customs Pay As You Earn (PAYE) records.
Figure 3. Remuneration of specialists, salaried (excludes self-employed), 2022 or latest available
Chart based on data published by the OECD. As a result of particularly notable data comparability issues Norway (which included specialists in training), Israel (which include all salaried physicians, full-time and part-time workers), and Sweden (which excludes overtime payments) are excluded. The OECD uses the following definitions:
- Remuneration is defined as the average gross annual income, including social security contributions and income taxes payable by the employee.
- ‘Specialists’ are defined as fully qualified physicians who have specialised and work primarily in areas other than general practice. Physicians in training should normally be excluded. To the extent possible, average annual income should refer to physicians working full-time.
- Salaried refers to physicians who are employees and who receive most of their income via a salary.
For physicians who are both salaried and operate in a self-employed or independent capacity, they are presented in the category under which they receive the majority of their compensation.
The earnings figures include: the values of any social contributions, (income) taxes, and similar payable by the employee even if they are actually withheld by the employer and paid directly to social insurance schemes, tax authorities and so on on behalf of the employee; all gratuities, bonuses, overtime compensation and "thirteenth month payments"; and any supplementary income (income from private practices for salaried physicians). However, they exclude, for salaried physicians, social contributions payable by the employer.
Wider economy average wages are based on the ‘mean’ value. Further information about the underlying data is available here.
Figure 4. Basic pay for junior doctors and consultants for 2023/24, by UK nation
This chart includes the newly agreed pay uplifts recommended by the 2023/24 Doctors and Dentists Renumeration Body (DDRB) report. Scotland, Wales and Northern Ireland have higher basic pay points for FY1 and FY2 (the initial stage of training after graduating from medical school) for those who take longer than one year to complete this stage of training, but we have excluded these for simplicity. The number of pay points for specialty training posts also varies between nations. For example, doctors in Scotland, Wales and Northern Ireland have a ninth and tenth pay band (which have been included in apostrophes in the x-axis of the chart). This analysis excludes non-basic pay components, which are calculated differently across the nations, so comparisons should be treated with caution.
Figures for England exclude geographical allowances, i.e. “London weighting”.
Suggested citation
Palmer W, Rolewicz L and Dodsworth E (2023) Exploring the earnings of NHS doctors in England. Explainer, Nuffield Trust.