The pandemic's biggest takeaway shouldn't be an NHS pay rise

Updated: Feb 13, 2022

The Covid-19 pandemic has put healthcare workers worldwide in the limelight, stressing underfunded health centres and workers at the core of the economy. Displays of courage and talent have grounded discussions of pay rises for healthcare staff (Kennedy 2020; Munn 2020; Gunawan 2020). To evaluate whether the pandemic alone justifies an increase in salaries for NHS workers, this essay proposes a cross country comparison, before discussing other motivations for pay rises. Relating this to demographic dynamics and the evolution of the National Health Service’s budget, I ultimately argue that the primary insight from the COVID-19 pandemic should be the urgency of investment in care, equal to health.

If solely concerned with the experience of COVID-19, the question of NHS worker pay raises may be summarised in three: (i) has the NHS performed poorly in the pandemic due low wages? (ii) Are there normative questions that clearly justify a financial award for NHS staff? (iii) Has COVID-19 harmed the attractivity of NHS employment?

The NHS has not faired worse in facing COVID-19 relative to higher public healthcare spenders. Public health expenditure in the UK was, as of 2014, a percentage point inferior to France, Germany, and Japan (Figure 1, Appendix). Points of comparison can be drawn on testing, vaccination, and excess mortality. Firstly, French, and German experiences display higher rates of positive results for fewer daily tests than the UK, which may hint to more intensive testing campaigns in the UK, not underperformance (Figure 2, Appendix). Secondly, despite a peak early on, excess mortalities in the UK have followed a group trend, still inferior to rates in Germany as of January 2022. Finally, the UK, though lagging later, was first to vaccinate 60% of its population out of this group of countries. Thus neither testing, treatment, nor vaccination campaigns in the UK depict a clear underperformance compared to higher public healthcare spenders.

Increasing salaries for NHS workers as a token of recognition strikes more sensitive debate. Though often omitted by media representations of COVID-19, key workers such as supermarket, online delivery or cleaning staffs have all reported severe cases of stress-induced burnout, stigmatisation, and low pay (May et al, 2021). Financially lauding NHS staff may omit the role played by wider populations, instigating social tension. Furthermore, pay-raise as state praise leads to further questions. Interpreted within state hierarchy, healthcare workers unable to reciprocate such a perceived gift could be come to seen as morally indebted to the state, as emphasised by anthropological work on vertical gifting (Yan, 2012). In short, expressing national recognition through increased wages raises problems necessitating further debate.

A third concern is the impact of COVID-19 on the employer attractivity of the NHS. Indeed, worker unions have warned of a nurse “exodus” post-covid (Ely, 2021). However, an increase of 32% in applications to nursing school in 2020 suggests that the pandemic could, in fact, have played in favour of labour demand in healthcare (Gallagher, 2021; Munn 2020). These students may have the private sector in mind, but a surge in interest for health studies is a silver lining for NHS recruitment.

The experience of the COVID-19 alone does not clearly motivate a pay raise for NHS staff. Calls to do so, however, precede the pandemic (Rimmer, 2017; Stephenson 2021).

The NHS has received modest funding for the past 10 years. The Department of Health’s budget growth from 2009-2019 has been twice inferior to its historical average (The King, 2019; Figure 9). From 2012 to 2017, GP, nurse and junior doctor real incomes dropped up to 17% (Rimmer, 2017; Ely, 2021). Depreciation in staff livelihoods has coincided with a drop in supply of nurses. 6% of them, coming from the EU, are 87% fewer since the Brexit referendum (Papanicolas et al, 2019). Entering the pandemic, the NHS listed 40,000 nursing vacancies. Pay, cited as the number one reason for 61% of nurses threatening to leave their profession (Nursing notes, 2021), is likely to be a primary reason. In short, renewed recognition offered by COVID may not compensate a decade of shrinking funding.

Such budget cuts have burdened a health sector faced with increasing challenges. From 2009 to 2019, the number of attendances to A&E were factored by a fourth (Figure 5) whilst waiting times have bloated (Figure 6). On average, the NHS performs worse in several sectors compared to 11 similar high-income countries (Papanicolas et al, 2019). Furthermore, demographic trends are likely to heighten national needs, as older population require higher spending (Figure 7). Indeed, the percent of the UK population over 85 is expected to near double, from 2.5% to 4.3%, by 2035 (Robards, 2022; Figure 8), while by 2066, one Briton in four is projected to be over 60. Staff shortages and low moral are likely to deepen the blow of these mounting pressures. For these reasons, as well as new investment in novel health technologies, the argument for a 13% pay raise for nurses called for by the Royal College of Nursing (2021) is grounded and understood. This reality, however, is not a symptom of COVID-19.

Instead, Covid-19’s major takeaway may well be a larger national neglect of care, both in government and in economics. Care work is defined as labour once reserved to the household, such as housework, child and elder support with close personal and emotional interaction (Folbre, 2006). Its fulfilment ground the basic physical, mental and developmental abilities of the national workforce. Neoclassical economic models, formed by markets in which households are opaque atoms, dismiss the care economy. Subsequent policy recommendations risk missing these activities, which are at the core of economic activity. Over the past decade, the largest budget cuts to social care – adult social care budget having dropped by 11% between 2009 to 2016 – has gone relatively unopposed. These cuts shift the cost of human needs to households and the private sphere, heightening socioeconomic inequalities (Dixon, 2019). By imposing lockdowns, cutting back on the service sector and causing economic recession, Covid-19 has uniquely stressed care activities, and is likely to have added to the frustration expressed in calls for higher NHS worker wages.

As Seguino (2017) argues, the care economy may take the brunt of a recession, as insecure job prospects increase stress on households. In addition to economic stress, COVID-19 stay-at-home orders have exacerbated unpaid workloads and mental strain (Kabeer et al, 2021; Gregory, 2021; The British Medical Association, 2020). Because UK care work remains a gendered reality (Hochshild, 1989, 1997; Henau and Perrons, 2018), this situation has translated to a regression of the cause for egalitarian gender role throughout the pandemic. Worldwide, reduced access to childcare services has constrained womens’ ability to work (United Nations, 2020), while housework has increased for teenage girls disproportionately to boys of the same age (UNICEF, Plan International, and UN Women, 2020). In the UK, as of February 2020, after a month of lockdown, UK mothers were 47% more likely than fathers to have left their jobs (Belkacem and Laugier, 2021, p15), and reported higher rates of stress worsened mental health(Power, 2020). As funds have decreased and Covid has stressed its importance, the gains from investment in social care have been repeatedly demonstrated: returns of up to £20 billion are projected for reintegrating disabled workers alone (Leonard Cheshire, 2021). In summary, rather than a recognised need for greater NHS funds, the pandemic has sorely stressed the consequences of underfunding care, and the urgency of its reinvestment.

This essay has argued that the experience of COVID-19 alone does not justify an increase in pay for health workers. Instead, calls for increasing NHS staff wages, in particular nurses, may be grounded by sector-wide vacancies and insufficient funding that pre-date the pandemic. The pandemic itself may instead support the urgency of investment in care. As the UK emerges from COVID-19, its ability to aid children, the elderly and those under stress will be a conveniently high return investment.

Edited by Archie Urey

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