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A separate pay spine for nursing staff

A fresh start for nursing

In January, the UK government launched a consultation to explore the creation of a separate pay structure, also known as a pay spine, for nursing staff working for the NHS in England.

More than 7,000 members working in the NHS and independent health and social care settings helped shape our response to the consultation. Thousands of our members told us their job descriptions don’t match the reality of their work.

In April, we submitted our response.

What we told the government 

  • Nursing needs a fresh start

    In the 20 years since the Agenda for Change (AfC) pay structure was introduced, nursing has transformed. AfC no longer provides equal pay for work of equal value. Patients and service users hold nursing staff in high regard. Politicians need to catch up.

  • Nursing is not a calling

    Or a vocation. Or ‘women’s work’. We are a profession. We are experts. We are leaders. There is an art and a science to what we do.

  • Nursing needs recognition

    Nursing support workers should be paid starter salaries in the region of £27,500, and registered nurses in the region £35,000, with progress towards £50,000. A path towards more advanced career levels should be clearly and credibly marked out.

    The previous experience of internationally educated nurses should be recognised – as happens in the medical workforce. In the UK, nurses educated overseas are automatically employed at the bottom of band 5, regardless of their experience in different countries.

    Patient-facing professionals in NHS pay band 2 are paid just a single penny more than the national living wage of £11.44 per hour. As valued members of the nursing team, they deserve far greater recognition.

  • Nursing needs a new career framework

    A new pay structure must be aligned to a new nursing career framework to allow professional development of nursing staff that is similar to the medical workforce in the UK, and the nursing workforces in the US, Australia and the Republic of Ireland.

'Give nursing its fresh start and a new place in health care'

This year, we’re opening the biggest public and political conversation about the value of nursing. And we’ll tell the sceptics why nursing is unique, why patients need us and why we deserve better.

We ask governments, the NHS and all employers to give nursing roles fair treatment.

What our members told us


The proportion of respondents who said their banding is appropriate or very appropriate – a significant drop from 44% in 2015*.


The proportion of respondents who don’t think that the difference between bands is significant enough to recognise the increased experience and requirements between roles.


The proportion of respondents who disagree or strongly disagree that their pay band recognises their knowledge, skills, education and responsibility.

*RCN Employment Survey 2023  

I manage complexity and acuity in a high-stress environment. I’m a highly skilled nurse with 14 years’ experience, a Diploma of Higher Education, a bachelor’s and master’s degree. In any other profession my salary would track my extended skills. This simply hasn’t happened. I get paid the same as a 1-year post midwife or other health care professional.

— RCN member


Registered nurses and nursing support workers in the NHS are paid under a contract and system known as ‘Agenda for Change’.

It came into force in 2004 and has not kept pace with the changes in the nursing profession in the 20 years since.  

It is unacceptable that despite years of experience, many nursing staff are still employed at the band they started their career on.

Today 42% of registered nurses working for the NHS in England are on band 5 salaries, the lowest salary for registered nurses.

The current system mostly rewards staff the further away they get from providing hands-on patient care. This approach is poor for patients and works against career progression for nursing staff. Routine pay progression from band 5 to 6 is afforded to some occupational groups but not nurses – that is unfair and unsustainable. 

During pay negotiations with the UK government in March 2023 the subject of how the NHS Agenda for Change (AfC) pay and grading structure affects career progression and professional development of nursing staff was discussed.

We proposed the option of a separate pay spine for nursing staff, and the government opened a consultation on this matter which closed on 4 April.

You have told us that limited career progression in nursing has a direct impact on recruitment and retention within the profession and has contributed to the staffing crisis in the NHS. Whether you take on management roles or not, your knowledge and excellence as a nursing professional has to be recognised. 

We believe a separate nursing pay spine and career framework would provide the unique solution required to address the acute nursing workforce crisis. It would also improve patient outcomes by recruiting and retaining the nursing workforce.

In our consultation response we have considered what a nursing pay spine could mean for all nursing roles, between bands 2 to 9.

Discussion of any potential nursing pay spine is ongoing, and the UK government’s consultation has gathered evidence and opinions from many organisations and individuals to understand the problem and possible solutions in the NHS in England. 

No, nursing staff working in the NHS have not yet received a pay award or pay increase of any kind for the 2024/2025 financial year.

This submission is a set of proposals that we believe would be a fresh start for nursing and a new place in health care. Through this consultation the UK government is considering what a potential pay spine for nursing could look like in future.   

We made clear in our submission that we support the current terms and conditions under Agenda for Change and would want to see them added to in any discussion of a new pay spine. We would not accept reduction or erosion of terms and conditions.  

We acknowledge that many nursing staff work within multi-disciplinary teams. The value of these teams is they draw medical and clinical expertise from across professions together to deliver patient care. By their nature different members of these teams are already employed under varied terms and conditions. Teams often include doctors, who are employed on a separate pay spine and agency workers paid entirely different rates. This has not given rise to industrial unrest nor their ability to act as ‘one team’ in terms of patient care.