From Vital Signs Magazine, Issue no.2
Have you ever looked at the NHS Job Evaluation Handbook? On first sight it is as easily understandable as the guidelines for UK custom duties post-Brexit or exciting as the construction manual for an IKEA shelving unit. But there are actually interesting aspects and this article will tell you why – last, but not least, because we should understand the system they use to justify not only paying us peanuts, but also different amounts of peanuts.
What’s it about?
As you might know there are 9 different pay bands in the NHS – although the minimum wage increase gobbled up Band 1, which is an irony in itself, so they can’t really use Band 1 anymore. It’s only a question of time – actually April 2025 – till they can scrap Band 2, too, it seems. Anyway, there used to be way more different pay categories, but it created a lot of tension and struggle amongst different groups of workers and egged them on to go on strike, so they stream-lined it at some point in the late 1990s. Each band, and with it each wage, is ‘evaluated’ through 16 different factors. One factor, for example, is ‘Planning and organisational skills’, another one is ‘Emotional effort’ and so on. Each factor has up to 8 different levels and for each level the job scores a different amount of points. But not only that, each factor is ‘weighted’ differently. For example, level 4 of ‘Knowledge, training and experience’ scores you 88 points, whereas ‘Working conditions’ or ‘Physical effort’ only 18. Have we lost you already, are your eyes glazing over yet? Here we can already see that, at least according to their seemingly ‘objective’ criteria, you deserve way more points, and therefore money, if your parents managed to get you into Oxford, compared to having to deal with excrement and obese patients every day, which will not only kill your back, but also yourself, relatively quicker.
In the following article we will go through the topic step by step. We first look at how the current system explains what the wage is and what the reasons for wage differences are and why we think it’s pretty shady. We then question in more detail their idea of ‘meritocracy’ – a fancy word, meaning, their assumption that people are paid more because they have done more to deserve it. That will be a bit philosophical, but you might like it. This is followed by a description of the internal flaws of the NHS banding system and why it creates loads of unproductive additional work. Then there will be a funny bit where we use the job evaluation guidelines to upgrade the HCA job category to a Band 8. We then explain why the pay differentials actually lower the wage for everyone – okay, nearly everyone! – and how they impact on our daily working life. We finally look at social alternatives.
We can sense that some of our readers are already pissed off: ‘I stressed myself out to get through the Trainee Nursing Associate or nursing management course and now these plonkers want to tell me that I don’t deserve a better wage?! Get lost!’. Easy! No one wants to take away nothing or deny that you done well – it’s about creating a better atmosphere and life for all of us.
Wages and wage differences
The current system tells us that wages are somehow either a fair share of the company’s profits, or a fair exchange for the work we are doing. Differences in wages are explained by the fact that people who earn more have done previous work to deserve it, e.g. by studying or by being smart. The reality is slightly different.
Wages are determined by the amount of money we need to maintain ourselves and our ability to work. So wages tend to drop to a certain minimum in order to increase profits. We can see that even with piece-rate systems or over-time payments, which seem to express a direct relation between the amount of work we do and the amount we earn. After a certain time the piece-rate is lowered and the over-time system adjusted, so that the wage drops again towards the necessary minimum. But there are other elements that define the wage and wage differences – and none of them are too pleasing to the eye either. We focus on three elements here.
Firstly, the situation on the labour market impacts on the wage level. We sometimes like to forget that our time and energy – our life-time and life-energy! – is a commodity with a price tag on it, a bit like a turnip or a fizzy drink. Who wants to think of themselves as a vegetable? If there is demand for labour, the price goes up, if there isn’t, it goes down. If we have a certain skill that is in more demand, the price goes up, but if the demand falls, so does the price – in many countries there are loads of pizza delivery drivers with all kinds of degrees that are not in demand. No one would pay them more, just because they made the effort to study!
Secondly, guess what, we actually are not like turnips or fizzy drinks – we are human beings that can organise themselves together and ask for more money. Last year the inflation was 10% and the government wanted to pay us NHS folk 1% more money. Only because we went on strike did we get more money – though still not enough to catch up with inflation. So wages are also a relation of power – we do the work, they profit and pay us peanuts, we get snarky and fight back, they also get snarky and so on. Often only a deep crisis or a war can drop wages back to the minimum, which is not coincidental. Which leads us to the third element.
Thirdly, differences in pay are a political means to stop us from uniting and fighting for more. This happens in different ways. A difference in pay makes the wage itself look fair – we pay the Band 3 HCA a bit more than the Band 2 HCA because they can prick peoples’ fingers or put a cuff around peoples’ arms. The NHS banding system is all about seemingly objective and scientific justification for pay differences. A difference in pay also creates divisions and jealousy amongst the work-force (“why did that bi%$ get the Band 6 job, not me?!), which is good if you want to defend your profits against a potentially united workforce. Last, but not least, you can pay some people more in order to buy their loyalty and to do your dirty job – here we think about people who are supposed to make us work harder or discipline us if we don’t.
So the rather ugly facts of exploitation, our lives being a commodity on the market and the necessary struggle between workers and bosses, are hidden behind the justification of pay differences. But isn’t there a good argument that if we don’t pay people differently no one would bother to make an effort or learn more?
The problem with the ‘meritocracy’
There is a certain sense of justice connected with the concept of meritocracy that we have to take seriously. Back in the day only men of a certain aristocratic background were able to take on privileged and better paid roles in society. Today, at least theoretically, you can become a judge or an orthopaedic surgeon even as a queer black woman. The fact that there are not many queer black female judges or knee surgeons might already tell us something, e.g. that also in the NHS things gets whiter and maler the further you go to the top, but it does not necessarily undermine the assumption that ‘if you work hard, you can get to places and better yourself’. Still, there are a few problems we see.
The main problem is that in our society production is not organised consciously with the aim to create a fulfilling and efficient work and life environment for all and by all. Time is money, and money is profit for some – so why spending time and resources on making peoples’ work lives more interesting? This means that the majority of people are stuck in relatively repetitive jobs, without much time and resources to learn or do something else. We live in a social pyramid, with relatively few jobs that require ‘lifelong learning’ or that have wider coordinating powers. So the main assumption of meritocracy that you can improve yourself is heavily limited by the scarcity of possible careers. The other assumption is that without sticks and carrots people would not do the necessary work and everyone would just slob around. The fact that most hospital workers work for very low wages instead of getting a better paid bullshit job elsewhere proves the contrary. People do care about what they are doing and they are blackmailed with it – ‘how can you ask for more money, think about the patients first’.
More often than not privilege breeds privilege. Whoever had a nice middle-class upbringing with books in the house and inspiring dinner conversations ends up doing better in school, of course with a little extra-tuition, perhaps. Instead of wasting away in a so-called ‘dead-end’ boring job they manage to continue learning and get a job that gives them a sense of independence and purpose. And on top of this privilege of having an intellectually enriching life they also get paid five or ten times more than the poor sister or brother who wasted away in the hamster-wheel – and will have a shortened life expectancy because of it. Should the latter not be compensated for the boredom and damaging impact of a routine job by earning more than the person who had the privilege to continue learning and take over wider coordinating powers? Of course there are also exceptions, people who come from poor backgrounds and ‘work their way up’. Can’t blame them and fair game, but that doesn’t make this model of society much healthier or even efficient. There are many studies that show that the greater the income differences in a certain area the lower the health standards and life expectancy of the poorer population.
A society where the majority of people cannot develop their capacities because they are trapped in repetitive jobs is not making the best of humankinds’ potential. A society that is built on an artificial hierarchy between a few specialists and a mass of labourers uses a large amount of resources to maintain that hierarchy and to compensate for its flaws. It also wastes a lot of talent, intelligence and creativity by confining people in tedious jobs. In our hospitals the wage gap between lowest and highest pay is not even that wide, ranging between around 25k for a Band 2 and 250k plus for the top bosses. Still, why should anyone get paid ten times more than a HCA who washes, feeds and cares for people day in and day out? And even more importantly, don’t we all have similar human needs, in terms of housing, food, leisure? People justify the high wages with the ‘social responsibilities’ the big managers have. At the BRI or Southmead, HCAs and porters slide or hoist hundreds of severely injured or sick patients every day – is that not one of the highest degrees of social responsibility? The hospital pays the big bosses only so much because otherwise they would bugger off to the private sector and run some wanky internet company or a hotel chain.
These were very general points for discussion. Now we will see how all this is also expressed in the concrete banding system of the NHS.
The questionable science of NHS job evaluation
As we have already hinted at, the NHS banding system is heavily geared towards maintaining the pay privilege of management. This happens in various ways.
The main issue is the weighting of factors. The factors where you can get the required points to go over Band 5 are ‘Knowledge’ and ‘Freedom to Act’. In particular the latter is slightly ironic, in the sense that your managing job gives you more ‘freedom to act’, which is a good thing, and on top of this privilege you also get more money – two birds! If your job requires a master degree you collect 150 or so points. The highest scores for ‘Working conditions’, ‘Emotional effort’, ‘Mental effort’, ‘Physical effort’ are 25 points each. So theoretically you could work in a sauna at 2am in the morning, up to your neck in C-diff induced diarrhea, helping the family of an end-of-life patient through their grief while concentrating on three different computer screens and simultaneously juggling with four full urinal bottles… and you would still only score 100 points. Even the highest level of ‘Physical skills’, that of a brain surgeon, will only score 60 points. So does the highest level of ‘Responsibility for patient care’ – and we thought it was all about the patients! And the other difference is that in the case of you slogging away in the sauna everyone would be able to see that you are doing an amazing job, while many jobs above Band 6 can be pretty opaque and less obvious: do they actually need that master degree or is that more of a quick common-sense indicator that you are probably not totally dumb and can adjust in an intellectual job role with other middle-class people? During banding panels managers freely admitted that although many official job descriptions required a master degree, this requirement was often ignored during the actual recruitment process due to a lack of suitable candidates.
Let’s take the example of the highest level 6 of ‘Communication and relationship skills’, which is worth a Band 7 or above. Here it says, and we quote from the Handbook, that Level 6 requires: “Communicating highly complex information in a hostile, antagonistic or highly emotive atmosphere”. Of course management might imagine having to speak in a boardroom, announcing budget cuts or something alike to other people in suits. But have you ever tried to convey in an overcrowded bay with slightly confused elderly men who haven’t been washed for a couple of days due to staffing shortage – some of whom speak only Albanian or heavy dialects from Newcastle – that unfortunately the TV remote has been lost and that they won’t be able to watch the footy tonight?! Or that unfortunately the dinner menu has been changed and there won’t be bangers, mash and gravy, instead just broccoli with rice?! Here we are really talking about “communicating highly complex information in a hostile or highly emotive atmosphere!” Good luck, mate!
Another way in which the banding process is geared towards managing roles is the basis on which the banding of new job roles takes place. The banding takes place using the job description of the new role and comparing it to existing jobs. Here are two issues with that. Firstly, it is pretty flimsy to just use a job description to band a new job. The job description has been written by another manager – and it is not surprising that people who find their own work important might write job descriptions for other managing roles in a way that scores similarly high. By using certain catch-words, such as ‘complex knowledge’ etc. it is possible to notch the banding of a job up the ladder a bit. Then the new job is not actually observed in reality, but only compared to another already banded job role – which itself has also probably only been compared to another job. You create a paper-chain of evidence. Last, but not least, the banding panel itself is dominated by managing roles, even if ‘staff side’ is formally represented.
But the system of maintaining pay differences is not only biased, it also requires large amounts of extra work. In one of the Bristol trusts there is a backlog of 40 – 50 jobs that need banding, that alone means that four people on Band 7 or Band 8 plus wages have to sit together for at least the same amount of hours, if not longer. Then there is another panel of mainly managers who check the ‘compliance’ – if they are not happy, it goes back to the banding panel, and so on. A very complex, and surely very expensive, software has been written to help with the banding process. There are national learning courses for banding panellists. Still, the amount of work is so significant that trust management now considers to outsource the banding process to a private company.
The system of pay differences is not primarily a management scheme to justify their privileges, it’s main result is to help lower wages for most of us, because it keeps us divided. We give ourselves the task to analyse the various management tasks more closely: which job roles or tasks are primarily there to coordinate patient care and the collaboration between different hospital and health departments – these tasks could be shared out more evenly amongst the wider workforce. And which management tasks are only there to stream-line work so that the tight budget (or rather budget cuts) can be implemented – basically doing the dirty work for the government.
With pay differences we all lose out
We can understand why people want to defend different pay scales. Many of us think that ‘working your way up’ is the only realistic way to earn more money, and who doesn’t need more money? But if we look at the impact of different pay scales we can see that it allows the government and top management to keep us divided and to prevent us from collectively fighting for more money for everyone. The different bands create quite a bit of competition and resentments amongst us, in particular between Band 5 and Band 6. Who will be promoted next? Do the Band 6 actually do more work in order to deserve the money? All this doesn’t create a good atmosphere at work and it doesn’t help improving our conditions together.
Even when we fight for better wages the pay scales are used to keep us separate. During the last pay round the government decided to give different percentage increases to different bands. Now the nurses union RCN considers leaving the national wage agreement, which would mean that they would only fight for nurses’ wages, not as part of the general NHS pay campaign anymore. Currently the junior doctors are on strike for higher wages – but they fight alone. They often emphasise that they are not paid enough, compared to other jobs. But if they would see themselves as part of the general workforce, their strike would be less isolated and more effective.
We can also understand why colleagues, in particular from the trade unions, are in favour of pay scales as a way to defend wages against dumping. Their logic is that the employer should pay for the skills that the worker has learnt. They are also correct when they say that the employer tries to force lower paid workers to take on more skills, e.g. HCAs and TNAs are now encouraged to do cannulation, and thereby devalue higher paid and more skilled work. Therefore, according to their logic, we have to use a strict interpretation of the pay bands and make sure that each skill is paid. We think that this is a very defensive view that doesn’t take into account that the system of pay scales divides and weakens the workforce collectively.
We also get that in particular nurses and doctors argue that they paid for their degree and worked many unpaid hours and that it would be unfair if they would receive the same wage as people who didn’t get the nursing degree. Again, our answer would be a joint struggle that nursing and medical degrees are free and all study time and work is paid equally at full wages.
What’s the alternative?
We are not sure ourselves, the following thoughts are up for debate! We think it would make sense that all NHS workers are paid the current annual average wage in the NHS – which would be a fair and cost-free redistribution. The mean annual earnings per person were £40,627 in the 12 month period up to the end of December 2023. Equal wages would increase our unity which we can use to fight for better conditions together. We could start by demanding that the £230 billion that the (shadow) government earmarked for re-armament programs for the coming years should rather be paid out to the NHS.
By paying everyone the same wage we would free extra-time which is currently required to band, re-band, evaluate the various job roles. This extra-time could be used to give all job roles more chances for learning, e.g. new medical skills or how to coordinate work in their department. This in turn would make most jobs less tedious and would mean less stress for current Band 6 or team-leaders, as the work-load and tasks would be shared more. Of course, some people can be clumsy or not particularly good at coordinating tasks, but they should not be extra-punished for their lack of talent by earning less money. In general it should be seen as a privilege in itself to be able to take on more complex tasks, something that doesn’t need additional privilege in money terms – and if you need an extra breather after you just performed a spinal surgery, just go ahead and chill for a bit.
More equal conditions within the NHS, both in terms of wages and in terms of job tasks, would set an example for other sectors. It would be dangerous for all those who profit from inefficient hierarchies, from expensive degrees, from divisions within the working class. But it might give many people hope that a more equal society is possible, where we are neither trapped in tedious low-paid jobs nor forced to compete with everyone else for a supervisor role in their rat-race.
