New research has found that ethnic minority NHS workers who are also born overseas face a double pay disadvantage due to the combined effects of ethnicity and migrant status
The NHS is one of the largest employers globally and comprises a highly diverse workforce, with 24% of staff from ethnic minority groups, compared to 18% of the UK population as a whole.
Migration status, often overlooked in Human Resources records, is closely tied to their placement within the Agenda for Change (AfC) pay bands. Researchers conducted the first analysis of the associations between ethnicity, migration status, and AfC pay bands using data from the UK-REACH cohort study.
The findings, which are published in JRSM Open, are significant and shed light on a crucial issue within the NHS workforce.
Analysing the pay grade of 5,7000 NHS workers
The Agenda for Change (AfC) outlines standard pay scales and career paths for NHS staff. The scheme operates on ‘Bands’, to which staff are allocated based on their education, qualifications, and experience. For example, Bands 5 and above are typically held by professionally registered individuals, while Bands 4 and below are generally reserved for administrative or support roles.
A previous large-scale study using routinely collected data on AfC revealed an ethnicity pay gap of 4.6% in favour of White healthcare workers (HCWs) compared to Black/Black British HCWs. This means that, on average, Black/Black British HCWs earn 4.6% less than their White counterparts, highlighting a significant disparity in the NHS workforce.
The researchers conducted a cross-sectional study of over 5,700 healthcare workers employed under the NHS Agenda for Change (AfC) pay scale, which encompasses staff, including nurses, midwives, and allied health professionals.
The team employed multivariable generalised ordered logistic regression models comprehensively to examine the associations between ethnicity, migration status, and AfC pay bands, while adjusting for sex, education level, job role, and years qualified.
The findings reveal that overseas-born staff face lower placement in higher AfC pay bands despite comparable qualifications
The researchers found that overseas-born staff were significantly less likely to be placed in higher AfC pay bands, even after adjusting for education, job roles, and years of professional qualification. In particular, Asian and Black healthcare workers born overseas were less likely to reach higher pay bands compared to their White UK-born and trained counterparts.
Lead author Dr Ji Soo Choi commented: “Our findings highlight that migration status plays a critical role in shaping healthcare professionals’ career prospects, yet this data is not routinely collected. These disparities cannot be addressed without first being recognised and recorded.”
Despite ethnic minority and migrant workers making up 24% of the NHS workforce, they remain underrepresented in senior positions within the AfC framework. Furthermore, migrant workers face additional challenges distinct from non-migrant NHS workers, including difficulties with international qualification recognition, limited professional networks, and restricted access to training. These challenges can significantly hinder their career progression and contribute to the disparities observed in the NHS workforce.
The lack of relevant data on migration status means that these issues are overlooked and not addressed in research, creating a knowledge gap that fuels workforce inequality. The researchers emphasise that NHS policymakers must include migration status in data collection to enable equality of opportunities for migrant workers.
The findings shed light on the lack of NHS workforce policies that address the barriers faced by migrant workers, including access to training, recognition of credentials, and opportunities for mentoring and leadership.
“Ethnic minority healthcare workers represent over a third of staff at NHS pay band 5, but their presence drops sharply to just 10% in senior roles,” said senior author Professor Manish Pareek. “This lack of diversity in leadership limits influence over key workplace decisions such as pay, scheduling, and policy, which may contribute to a less supportive environment for ethnic minority staff. These inequalities risk driving higher attrition rates amid the NHS’s ongoing staffing challenges, further exacerbating the workforce inequality and potentially compromising patient care.”
