In 2020, the Secretary of State for Health and Social Care confirmed the Senior Salaries Review Body (SSRB) would bring NHS very senior managers (VSMs) within its broader remit offering independent advice on pay for senior staff in the UK public sector. The SSRB was first asked to provide observations on VSM pay in 2021, followed by recommendations in 2022 and it is within this context that we submit evidence to the independent review body on behalf of NHS trusts and foundation trusts. Our key messages are as follows:

• We are generally encouraged by discussions and developments around a new VSM pay framework. Trust leaders want to see the creation of a single framework which does not separate providers by trust type and moves away from financial turnover as the primary criteria for determining levels of executive pay.
  
  
• Trust leaders have been under enormous pressure throughout the COVID-19 pandemic, dealing with the unprecedented demand for emergency services, the push to recover the backlog in care and the delivery of a national vaccination programme. These sustained pressures are damaging to mental and physical wellbeing, with VSMs experiencing burnout in a similar way to frontline staff.
  
  
• Our data does not point to widespread, persistent vacancies on boards and it is usually possible to fill posts. However, we are concerned about the high levels of turnover, with one fifth of executive directors having been in post for a year or less and nearly half (44%) being new to their roles within the past two years.
  
  
• We would strongly support the removal of unpopular and ineffective ‘earn-back’ policies from the VSM framework and believe the government should ensure a return to cost of living pay increases for the remit group in 2022.
  
  
• The “Messenger review” of health and social care leadership in England presents an opportunity to improve overall leadership capability and capacity across the service, but it must not veer towards outright and sustained criticism of the job carried out by senior leaders. It must also ensure a focus on improving leadership diversity given the low rates of representation at board level and unequal opportunities for ethnic minority staff to advance in the NHS.
  
  
• The SSRB and government must keep a watchful eye over ongoing challenges for the remit group, including those influenced by the move towards ICBs as statutory bodies and issues surrounding pension taxation. As the nature of VSM roles evolve, it is essential the right incentives are in place for developing leaders to take, and remain in roles on trust boards.

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