The NHS Agenda for Change (AfC) framework is one of the largest national pay frameworks in Europe. Created in 2004, it attempted to harmonise the pay and terms and conditions of over one million employees—covering most NHS workers in all four nations of the UK.

Before AfC was introduced, pay rates for the same roles at different NHS employers could vary wildly. Equal pay claims were commonplace and workplace grievances about earnings regularly put pressure on employers. Although AfC was far from perfect, it had the desired effect of limiting these disputes and has broadly held steady for over 20 years.

Negotiations between trade unions and NHS employers to reform the framework got underway earlier this year following a funded mandate from the UK, Welsh and Northern Irish governments, and are expected to resume this autumn following the recent change of government. The last time AfC saw any significant change was in 2018, as a result of a three-year pay deal. Those reforms removed overlapping pay points between bands, reduced the number of incremental steps and accelerated progression to the top of pay scales. It streamlined the framework, making some improvements, but it was not enough to address the structural issues still prevalent today.

Any further changes introduced by these talks, including any pay increases, will be backdated to April 2026 and will be funded with additional money on top of the 3.3% already awarded to staff.

With job cuts, rising pressure on services and ongoing restructuring, these talks are not the immediate focus for most NHS staff, including many MiP members. But there is a great deal at stake. Most NHS unions, including MiP and UNISON, will consult members on next steps, whether a deal is reached or the talks break down.

The outcome will determine if unions move on from the 2026 pay round—or move into a formal dispute. The staff side position is clear: the 3.3% imposed award is not enough, and these talks represent the government’s last opportunity to rebuild trust and deliver improvement.

While a radical overhaul of the framework seems unlikely, there is now a consensus that parts of AfC no longer reflect the realities of a modern workforce. Which parts of the framework will be up for discussion has not been confirmed, but the scope of the discussions will depend on how much money the government is willing to put down—a figure which also remains unknown.

While nothing has been ruled out, the UK government has given negotiators a direction of travel, saying its priorities will be to improve pay “for those in the lowest bands” and for graduates “across all professions”.

Unions support this direction. Pay in the lower bands is struggling to keep pace even with the minimum wage, let alone the real living wage, and compression at this level is weakening incentives for progression. Entry-level graduate roles in the NHS at Band 5 also lag behind equivalent roles in the public and private sectors, risking the long-term supply of talent into the NHS.

But for reform to deliver meaningful change, it must go further. The recent NHS staff survey in England highlights the scale of the challenge: only a third of staff are satisfied with their pay and nearly a third frequently consider leaving their role. There has also been a decline in the proportion of staff who would recommend their organisation as a place to work.

Alongside dealing with pay compression in the lower bands, action is also needed at the upper end of the scale. The pay differential between Bands 7 and 8A has narrowed over time, meaning the increase in responsibility, accountability and workload between the bands is not matched by a proportionate rise in pay, actively discouraging progression into senior roles.

Worse still, most managers moving into Band 8A lose all eligibility for overtime and unsocial hours payments. While this is supposed to reflect a more regular working pattern with greater flexibility in managing working hours and workload, the reality is that most managers are regularly working additional hours without any compensation, contributing to burnout and work-related stress. While staff in Bands 8A to 9 should be able to access time off in lieu instead of overtime, we know from our members that this is rarely granted in practice.

As a result, promotion can in some cases lead to lower take-home pay. This isn’t right. Combine this with the long wait for pay progression and you can see why this specific bottleneck was the primary issue for the NHS pay review body when it started this process by recommending action to address structural issues in AfC.

MiP has long called for action here and welcomed the introduction of an intermediate pay point for Bands 8A to 9 in 2024. However, staff still have to wait five years to reach the top of their band. More must be done to ensure promotion is well rewarded and pay progression reflects both experience and merit.

The NHS is also increasingly struggling to recruit and retain senior managers, as pay for many leadership roles fails to compete with the private sector and other parts of the public sector. Roles such as operational managers, programme directors, digital specialists, finance managers and transformation leads can often command significantly higher salaries elsewhere, often in less demanding environments.

The NHS pay system needs the flexibility to retain its staff and attract managers with the necessary skills to deliver the government’s priorities.

The job evaluation system that underpins AfC is also under increasing strain. Designed in the early 2000s, it is widely seen as poorly suited to modern NHS roles. Digital, data, integrated care system leadership and other complex senior roles—many of which didn’t exist 22 years ago—often sit uneasily within existing job profiles.

Despite national guidance, different NHS organisations can reach different banding outcomes for similar roles, leading to unequal pay for comparable work. MiP believes all staff should have a right to request an annual band review, but this would require a significant strengthening of job evaluation capacity across the NHS. The system must be properly funded and managers need adequate training and support to apply it consistently.

Ultimately, the success of these talks will not be judged by one single issue, but by whether AfC is made fit for a workforce that has changed fundamentally since it was introduced.

NHS roles are now more complex than ever, but the pay system has failed to keep up. Without meaningful reform, existing structural pressures will continue to undermine morale, weaken retention and limit efforts to improve productivity and patient care.

Once talks have concluded and a deal is on the table, MiP will consult members immediately: you will have your say on your pay. Please make sure you are subscribed to MiP emails and check the website regularly for updates. You will decide what happens next.

In the meantime, MiP will continue to make the case for a system that makes progression fairer, rewards responsibility properly and addresses long-standing compression at both ends of the pay scale. A modern NHS needs a pay system that properly reflects the value of the people who keep it running. //