Senior Salaries Review Body 2027/28: written evidence from the NHS Alliance

We welcome this opportunity to submit evidence to the SSRB. The topics covered in this submission have been chosen based on requested areas for evidence listed by the Senior Salaries Review Body, and our members’ views.

• Very senior managers (VSMs) in the NHS are working in an extremely pressurised environment due to a historically tight funding settlement, rising operational demand, a challenging recovery trajectory, an ambitious reform agenda, and a wide-ranging structural reorganisation of the service.
• The NHS Alliance’s governance and regulation survey, conducted this summer, found that NHS leaders tend to see the VSM pay framework overall as a useful tool that helps recruitment and retention. However, many respondents felt using turnover as the sole metric for differentiating between provider trusts was too simplistic and underestimated the complexity and difficulty of VSM roles in smaller organisations. We ask the SSRB to recommend this is reviewed and a greater variety of factors should be considered.
• The pay scales for integrated care boards (ICBs) are no longer fit for purpose as they are based on the size of population covered. However since they were set, many ICBs have merged or have begun the process of merging, meaning the lower end of the scale is no longer applicable to any ICB, while the upper end contains a disproportionately large number of ICBs, with some in this bracket twice the size of some others.  
• We ask the SSRB to recommend that the requirement for national signoff for salaries over £170,000 should be removed, as it delays the appointment process for significant numbers of VSMs being hired on rates within the pay framework. We suggest national signoff should be applied only to salaries that are outside the national framework. If the threshold is kept, it should be raised significantly or as a minimum rise annually in line with the cost of living award.
• The top of the Agenda for Change pay scale is higher than many entry-level VSM salaries, and this creates a disincentive for high performing leaders to seek promotion. To avoid exacerbating this issue, we recommend that the VSM pay award for 2027/28 should be at least in line with both inflation, and the AfC award, and action should be taken to create meaningful step up.
• While NHS leaders recognise that there may be value in linking pay to performance, a large majority do not support withholding the cost of living pay award from VSMs in struggling organisations. This policy is seen as punitive rather than positive, and makes working in the most challenged organisations less attractive when the opposite is needed. We believe this penalty should be removed, and if it must be kept, widening exemption criteria to enable competent VSMs to receive their annual cost of living award.
• At the time this evidence was submitted, five and a half months into 2026/27, VSMs in trusts and ICBs had still not received their annual cost of pay uplift, and had not been told whether they would be subject to any exemptions in the award, for example due to poor organisational performance. This is an unacceptably long delay, and runs counter to the welcome recognition from the government this year of the contribution made by senior NHS leaders.
• Ethnic minorities are under-represented in VSM roles compared to the NHS workforce as a whole. Dissatisfaction related to opportunities for promotion, training and progression is a strong predictor of ethnic minority leaders’ intention to leave the NHS. Work on equality, diversity and inclusion must continue in the interests of talent retention and better patient outcomes.