Pay gaps in medicine and the impact of COVID-19 on doctors' careers

Gender equality and the gender pay gap in medicine have been long-standing problems globally.¹ Concerns about a large gender pay gap in medicine prompted the Department of Health and Social Care in England to commission an independent review, Mend the Gap: the Independent Review into Gender Pay Gaps in Medicine in England,² that has now been published and which we led. This review shows that the total medical gender pay gap in England is 24·4% for hospital doctors, 33·5% for general practitioners, and 21·4% for clinical academics.² The pay structure in UK medicine was designed for the health system of 1948, when the UK's National Health Service (NHS) was established, and has not kept up with the changes in women's position in society. These new data on the gender pay gap in UK medicine are likely to be mirrored internationally;³ the gap is fairly easy to measure in England because the NHS is a single employer.

The gender pay gap in medicine review gathered evidence from the NHS Electronic Staff Record, linked to workforce and tax records, and triangulated with survey data from a randomised selection of doctors on the General Medical Council register, and in-depth qualitative interviews. Results confirm a large overall pay gap with several underlying causes. Some of the causes, such as men having, on average, been in the workforce for longer, or the fact that women are more likely to have children and to work part-time, are not a surprise. However, a less well recognised factor is the way that pay progression is structured. NHS medical pay increases in an automatic and incremental way over several years. This structure means the easiest way to accrue a large salary is to be in the system for a long time, with no breaks, resulting in widening pay gaps for those who take time off, most of whom are women. This pay gap grows with increasing age and does not narrow until age 65 years.

This review was undertaken before the COVID-19 pandemic and the impacts of the pandemic on doctors' pay gaps are not yet fully understood. However, the COVID-19 pandemic is likely to have sharpened the disadvantageous effects of work circumstances, especially for female and Black, Asian, and minority ethnic (BAME) doctors.

The necessity to adjust working hours to manage serious overwork and the worsening imbalance of work and life during the pandemic typically results in missed experience and leadership opportunities for women⁴ and pay penalties over and above missed hours.² Similarly, the severe reduction in child-care provision will have disproportionately stalled the careers of women in medicine. Inadequate accessible child-care for UK medics has been shown to contribute to limited career progression.⁵ During the COVID-19 pandemic it is likely that most accommodations to adjust to the shortage of child-care will have been made by female doctors;6, 7 the implications for the female primary caregiver in dual medical career couples are probably exacerbated by both these factors.8, 9, 10

Women doctors are already regarded by some employers as less committed than men to a career.11, 12 The assumption that most women will be predisposed to prioritise family life, even if they have no children, is already damaging to their prospects of career progression.

Furthermore, the disadvantageous effects of the COVID-19 pandemic are likely to be compounded for female ethnic minority doctors. Pre-existing assumptions and stereotypes unduly affect female BAME professionals.¹³ Moreover, BAME doctors are more likely to be in patient-facing roles and it is possible that workplace systems and discrimination may contribute to feeling pressurised to work without adequate personal protective equipment.14, 15 In the UK, deaths from COVID-19 in the health workforce are highest among BAME health-care workers.16, 17

Further investigation of our review datasets to look for pay gaps related to ethnicity suggest that the pay gap is wider for women in minority ethnic groups than for White women; the groups most affected are Pakistani and Bangladeshi women with pay gaps of 30% or more. Explanatory factors, such as age and part-time working, do not remove all ethnic and gendered pay disadvantage relative to White men. The reasons for this may include structural inequalities or discrimination.

The COVID-19 pandemic has highlighted inequalities in the medical workforce.15, 17 Our concern is that these inequalities have exacerbated gender pay gaps in medicine, especially for BAME women. Our report makes recommendations to reduce the pay gap in medicine (panel ), which will be beneficial for women and for BAME colleagues. A first step in this process is an analysis of ethnicity and intersectional pay gaps.

Panel. Recommendations across seven themes to reduce the gender pay gap in medicine.

• 1Address structural barriers to the career and pay progression of women
• 2Make senior jobs more accessible to more women
• 3Introduce increased transparency on gender pay gaps
• 4Mandate changes to policy on gender pay gaps
• 5Promote behaviour and cultural change
• 6Review clinical excellence and performance payments and change accordingly
• 7Implement a programme for continued and robust analysis of gender pay gaps

This online publication has been corrected. The corrected version first appeared at thelancet.com on September 23, 2021