We welcome the opportunity to submit evidence to the Senior Salaries Review Body (SSRB) on behalf of NHS trusts and foundation trusts, to inform the 2025/26 pay round for very senior managers (VSMs) in the NHS.

• Context: Supporting, developing, and retaining VSMs is essential if the NHS to meet the challenges it faces, and deliver on the policy objectives being set by government. It needs the best possible people at its helm. Despite a public narrative which suggests a bureaucratic and over-managed healthcare system, there has been a 15% reduction in recruitment of senior leadership since 2009. Percentages of our members reporting negatively on their morale remain worryingly high but have improved significantly since last year. Trusts are operating under serious pressure, with the scale of demand continuing to outstrip supply. Despite this, data from September shows that trusts are increasing activity and improving performance against national targets.
• Trust finances: The financial situation for NHS trusts is currently very challenging. However, approximately half of providers are now on track to meet their plans. When asked what actions may need to be taken to manage or improve the financial position of their trust, 85% of our members said it is very likely or likely that their trust will have to reconfigure services.
• Pay levels: Given the challenging nature of the job, fair remuneration for VSMs is crucial. We believe that pay levels for this group are broadly appropriate, but annual increases should map across to equivalent roles in other sectors, to ensure this remains the case.
• VSM pay 2023/24: Our members reported an average (mean) basic salary for all executive directors in 2023/24 of £151,515, a slight decrease compared to the previous year (£152,763). The median salary, which is less affected by outliers, increased for most role types. This suggests that salaries around the middle of the distribution were higher in 2023/24 than 2022/23.
• VSM pay framework: We are expecting the long overdue new VSM pay framework to be published in March 2025. Alongside this, we would welcome a commitment to updating it every two years, and consultation on its content.
• Approach to VSM pay awards: The Secretary of State’s newly announced intention to block some VSMs from receiving pay increases appears counter intuitive to the SSRB process, and the process for this will need clarifying within the upcoming VSM pay framework. Proposals will need to take systemic issues into account.
• Ministerial salary sign-off: We would like to see confirmation from government that the four-week sign-off period for salaries above £150,000 will be formally introduced, and when this will be done by. Ultimately, we hope that the upcoming VSM pay framework will remove the need for this sign-off process.
• Turnover: 48% of all NHS trust executive directors responding to our survey have been appointed since the start of 2022 and 67% had been appointed since the start of 2020. 58% are in an NHS trust chief executive role for the first time, a similar proportion to last year’s survey findings (60%).
• Shared leadership: Shared leadership roles are still becoming increasingly common. Our survey found 13% of executive director roles shared with another trust, a notable increase from 8% in last year’s survey. All roles saw an increase in the proportion that were shared compared to last year.
• Board diversity: Although overall ethnic diversity amongst board members has increased to 10.8% (up from 9.7% in 2022), these figures are still too low, and there must continue to be improvements. It is positive to see that there has been an increase in the number of trust board members reporting themselves as disabled.
• Trust league tables: We await further detail on the Secretary of State’s proposals for performance league tables for trusts. We are clear that they must not result in unintended negative consequences, and must be managed carefully, in the context of each organisation and the population that it serves.
• Talent pipelines: Progress on talent development and pipelines as a whole has been slow following initial plans from NHSE to develop a three year roadmap for 2024/25-2026/27 (which has not yet been published). We would welcome more clarity on national plans to support and develop NHS leaders.
• Non-executive director (NED) and chair remuneration: While out of scope for the SSRB, we feel it is pertinent to flag that our members are still increasingly concerned about NED and chair remuneration, which has remained relatively static for a number of years. NEDs and chairs are central to the performance management of VSMs and trusts as a whole and take considerable accountability as part of the unitary board structure in navigating operational and financial pressures, levels of risk, and the complexities of system working.