Intended for healthcare professionals

Feature Data Briefing

The gender pay gap in the NHS

BMJ 2018; 361 doi: (Published 09 April 2018) Cite this as: BMJ 2018;361:k1541
  1. John Appleby, director of research and chief economist
  1. Nuffield Trust, London, UK
  1. john.appleby{at}

The new requirement for large employers to publish basic data shows the scale of the discrepancy in the NHS—but less about why and what should be done, says John Appleby

At the time of writing (3 April), 9406 businesses with more than 250 employees across the UK had reported details of the gender pay gap in their organisations as at March 2017,1 as part of the requirements of the Equality Act 2010 (Gender Pay Gap Information) regulations published last year.2 This addition to the 2010 act stipulates some basic pay data: essentially, the percentage difference between men’s and women’s average hourly mean or median basic pay, the same for bonus pay, and the proportions of men and women between the quartiles of an organisation’s pay range.

With over 1.6 million staff, the NHS is the largest single employer in the UK, three times the size of the largest private sector employer, Tesco. Most NHS organisations (principally trusts) employ more than 250 staff. So what do the data tell us about the gender pay gap in the NHS?

A total of 220 NHS organisations—214 trusts and the Department of Health, National Institute for Care and Health Excellence, Health Education England, Public Health Wales, NHS Resolution (formerly the NHS Litigation Authority), and NHS Digital—have published data on the gender pay gap. Of these, 201 (92%) report a pay gap in favour of men ranging from 0.1% (Lancashire Teaching Hospitals) of median hourly pay to 52.5% (Health Education England). Eight organisations report no difference and 11 a difference in favour of women (fig 1).

Fig 1
Fig 1

Proportions of NHS and non-NHS organisations by size of gender pay gap

Compared with all organisations, those in the NHS are (on the limited number of current reports) more concentrated in terms of their pay gap. The gap in the 9186 non-NHS organisations ranges from 85% in favour of women to 85% in favour of men (fig 1). Overall, around 78% of non-NHS organisations pay men more than women.

Another way to look at the gender pay gap is in terms of the proportions of men and women in each quarter of organisations’ pay distribution. With women making up over 77% of the NHS workforce,3 it is no surprise that there tends to be a higher proportion of women than men in every quarter. However, the proportion of women above the top pay quartile tends to be lower than that below the bottom quartile in virtually all NHS organisations (fig 2). And this under-representation of women in the top quarter correlates with a pay gap favouring men (fig 3).

Fig 2
Fig 2

Proportion of women in top and bottom quarter of pay range in NHS organisations

Fig 3
Fig 3

Relation between gender pay gap and gender composition in top and bottom quarter of pay range in NHS organisations

Although the new requirements for reporting the gender pay gap are a step forward in understanding the scale of pay differences, in themselves they say little about underlying causes and possible policy prescriptions—at least at a national level.

Locally, NHS organisations, which will need to get to the heart of why they have a pay gap, will have much more detailed data on pay, by staff group and including overtime payments, for example. A next step therefore will be to decompose the reasons for reported pay gaps. Are higher paid occupations in NHS organisations dominated by men? Do men tend to dominate higher pay grades? To what extent does maternity leave affect women’s pay trajectory once they return to work?

But disentangling the reasons for the gender pay gap needs not only much more data (and local analysis) than is currently being published but a view on what might justify pay differences between men and women.

While pay gaps may exist even if a business pays equally for equal work, there may be wider societal inequalities (of access to education, say) that account for pay differences and that need to be tackled.

The gender pay gap isn’t just a matter of fairness for staff, however. In the NHS we know from staff surveys that there is a link between, for example, the proportion of staff “believing [their trust] provides equal opportunities for career progression or promotion” and patients’ experience of the care they receive.4 Ensuring that all staff are treated fairly in terms of their pay and the factors (such as career progression) that are likely to be important in explaining the gender pay gap is the right thing to do, not only for staff but for patients too.


  • Competing interests: I have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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